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Imagery rehearsal in the treatment of posttraumatic nightmares in Australian veterans with chronic combat‐related PTSD: 12‐month follow‐up data
Abstract
Nightmares are often a distressing symptom for veterans with chronic combat‐related posttraumatic stress disorder (PTSD). A psychological treatment that has recently shown considerable promise is Imagery Rehearsal Therapy (IRT). In a pilot study by the current authors, IRT was demonstrated to be effective in the treatment of posttraumatic nightmares in a group of combat veterans up to 3‐month posttreatment. This study reports the 12‐month follow‐up data of the pilot study, examining the longer term outcome of the IRT treatment. Twelve Australian Vietnam veterans with chronic combatrelated PTSD were treated with 6 once weekly sessions of imagery rehearsal and assessed using standardised measures of nightmare frequency and intensity, PTSD, depression, anxiety and broader symptomatology at intake, posttreatment, and 3‐and 12‐month follow‐up. Significant improvements in targeted nightmare frequency and intensity were evident to 12‐month posttreatment. Similarly, improvements in overall PTSD, depression, anxiety, and broader based symptomatology were also maintained to 12 months. This study provides preliminary evidence that the positive treatment effects of IRT on posttraumatic nightmares, PTSD, and broader symptomatology in males with chronic combat‐related PTSD are maintained in the longer term.
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Most studies of IRT focus on adults with classic PTSD, with limited research in adolescents or CPTSD populations.
“However, most studies focus on adults with “classic” PTSD, with limited research in adolescents or in CPTSD populations [31, 33, 34].”
From Efficacy of imagery rehearsal therapy in the treatment of traumatic nightmares in youth with complex post-traumatic stress disorder (2026) · cites this paper as [34]
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“Several studies have found a positive effect of IRTon nightmare frequency and nightmare distress (Forbes et al., 2001, 2003; Krakow, Hollifield, et al., 2001; Krakow, Johnston, et al., 2001; Krakow, Kellner, Neidhardt, Pathak, & Lambert, 1993; Krakow et al., 1995; Lu,Wagner, VanMale, Whitehead, &…”
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“…randomized controlled trials, they consistently demonstrated the efficacy of IRT to reduce both the frequency of nightmares (Davis & Wright, 2005; Forbes et al., 2003; Germain & Nielsen, 2003; Kellner, Neidhardt, Krakow, & Pathak, 1992; Kellner, Singh, & Irigoyen-Rascon, 1991; Krakow, Johnston,…”
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El-Solh, A. (2018) · Nature and Science of Sleep · doi:10.2147/nss.s166089 · Cited by 75
“32,33 However not all investigations involving veterans with PTSD have yielded positive results with IRT.”
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“Forbes et al. (2001, 2003) reported resolution of the target nightmare in a majority of their sample; in our sample this was infrequent.”
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“IRT is a manualized therapy for nightmares (Forbes et al., 2003).”
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“Nevertheless, the prevalence of these chronic nightmares seems significantly more frequent in individuals with psychiatric disorders [11].”
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“These findings are consistent with those of other studies that have examined similar treatments for trauma-related nightmares (e.g., Forbes et al., 2003; Krakow et al., 2001).”
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“…studies have indicated that interventions designed specifically to reduce nightmares and other sleep disturbances in adults with PTSD improve both individuals’ sleep and daytime PTSD symptoms (Forbes et al., 2003; Germain, Shear, Hall, & Buysee, 2007; Krakow et al., 2001; Raskind et al., 2003).”
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“Further, treatments directed specifically at nightmares also improve other PTSD symptoms (Forbes et al., 2003; Germain, Shear, Hall, & Buysse, 2007; B. Krakow et al., 2001; Moore & Krakow, 2007) and treatments directed specifically SLEEP AS A MEDIATOR 351”
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“There is increasing evidence that post-traumatic nightmares may respond to an empirically promising cognitive-behavioral treatment (CBT) called Imagery Rehearsal (IR) ( Forbes et al, 2003 ; Krakow et al, 2001 ).”
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“…1983; Spoormaker & van den Bout, 2006), middle-aged adults (Burgess, Gill, & Marks, 1998; Krakow, Hollifield, et al., 2001; Krakow et al., 2000; Krakow, Johnston, et al., 2001; Neidhardt, Krakow, Kellner, & Pathak, 1992), and veterans (Forbes et al., 2003; Nappi, Drummond, Thorp, & McQuaid, 2010).”
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“For example in Canada, 46.7% of the military population are female and 52.6% of MM are below the age of 39 [2].”
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Bryant, R. A., Wyzenbeek, M., & Weinstein, J. (2010) · Consciousness and Cognition · doi:10.1016/j.concog.2010.11.004 · Cited by 30
“Several trials have found this approach reduces the occurrence of unwanted dreams (Forbes et al., 2003; Krakow et al., 2001).”
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“In a 12-month follow-up study on the same veterans, results showed that gains continued with regard to nightmares and PTSD indicating long lasting treatment effects (Forbes et al., 2003). Specifically, the number and intensity of nightmares improved as did depression, anxiety, and overall PTSD symptoms. The cautions i…”
BackgroundInfluentialPsychosocial treatments for nightmares in adults and children: a systematic review
Gill, P. R., Fraser, E., Tran, T. T. D., Collier, G. D. S., Jago, A., Losinno, J., & Ganci, M. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-04703-1 · Cited by 31
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Nightmares: Knowledge and attitudes in health care providers and nightmare sufferers
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“…2006) is aimed at changing the nightmare content using imagination and appears to be effective in patients with post-traumatic stress disorder (Forbes et al., 2001, 2003; Krakow et al., 2001a, b), as well in patients with idiopathic nightmares (Krakow et al., 1993; Germain and Nielsen, 2003;…”
BackgroundSleep in Psychiatric Disorders
Franzen, P. L., & Buysse, D. J. (2017) · Springer eBooks · doi:10.1007/978-1-4939-6578-6_46 · Cited by 23
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“Well established waking state treatments, such as EMDR, IRT, and group exposure therapy establish a safe environment and a clearly spelled-out methodology before guiding the patient in intentionally recollecting and reprocessing the distressing memory.”
InfluentialPsychotrauma and effective treatment of post-traumatic stress disorder in soldiers and peacekeepers
Vitzthum, K., Mache, S., Joachim, R., Quarcoo, D., & Groneberg, D. A. (2009) · Journal of Occupational Medicine and Toxicology · doi:10.1186/1745-6673-4-21 · Cited by 21
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Rhudy, J. L., Davis, J. L., Williams, A. E., McCabe, K. M., & Byrd, P. M. (2008) · Behavioral Sleep Medicine · doi:10.1080/15402000802162539 · Cited by 19
“Moreover, successful cognitivebehavioral treatments (CBTs) that specifically target chronic nightmares reduce symptoms of PTSD, depression, and panic; therefore, chronic nightmares could be a significant maintaining factor of psychological distress (Davis & Wright, 2007; Forbes et al., 2003; Germain & Nielsen, 2003; K…”
BackgroundAn Expert Consensus Statement for Implementing Cognitive Behavioral Therapy for Nightmares in Adults
Pruiksma, K. E., Miller, K. E., Davis, J. L., Gehrman, P., Harb, G. C., Ross, R. J. M., Balliett, N. E., Taylor, D. J., Nadorff, M. R., Brim, W. L., et al. (2025) · Behavioral Sleep Medicine · doi:10.1080/15402002.2024.2437634 · Cited by 18
“…(IR) a adapted by Forbes et al. (2003) from the protocol of Thompson et al. (1995); [3] IR b adapted by Nappi et al. (2010) from the protocols of Forbes et al. (2003), Thompson et al. (1995), and Krakow and Zadra (2006); [4] Image Rehearsal Therapy (IRT) a which includes written exposure to the…”
Albanese, M., Liotti, M., Cornacchia, L., & Mancini, F. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.866144 · Cited by 20
Monitoring the mental well-being of caregivers during the Haiti-earthquake.
der Auwera, M. V., Debacker, M., & Hubloue, I. (2012) · PLoS Currents · doi:10.1371/4fc33066f1947 · Cited by 16
MULTIMODAL BEHAVIORAL TREATMENT OF NONREPETITIVE, TREATMENT-RESISTANT NIGHTMARES: A CASE REPORT
Tanner, B. A. (2004) · Perceptual and Motor Skills · doi:10.2466/pms.99.3f.1139-1146 · Cited by 15
Altered sleep behavior in a genetic mouse model of impaired fear extinction
Fritz, E. M., Kreuzer, M., Altunkaya, A., Singewald, N., & Fenzl, T. (2021) · Scientific Reports · doi:10.1038/s41598-021-88475-2 · Cited by 17
Exploring the Dreams of Canadian Soldiers with Content Analysis
Dale, A., DeCicco, T. L., & Miller, N. (2013) · International journal of dream research · doi:10.11588/ijodr.2013.1.9427 · Cited by 12
Stability of nightmare frequency and its relation to neuroticism: A longitudinal study
Schredl, M., & Göritz, A. S. (2020) · Journal of Sleep Research · doi:10.1111/jsr.13126 · Cited by 11
“On the other hand, therapy studies with long-term follow-ups (1–4 years) indicate that treatment success is stable over time (Forbes et al., 2003; Grandi, Fabbri, Panattoni, Gonnella, & Marks, 2006; Krakow, Kellner, Neidhardt, Pathak, & Lambert, 1993).”
Sleep in Psychiatric Disorders
Franzen, P. L., & Buysse, D. J. (2009) · Elsevier eBooks · doi:10.1016/b978-0-7506-7584-0.00032-x · Cited by 11
Sleep Disturbances in Posttraumatic Stress Disorder
Germain, A. (2009) · Psychiatric Annals · doi:10.3928/00485713-20090514-02 · Cited by 10
Taylor, D. J., Pruiksma, K. E., Mintz, J., Slavish, D. C., Wardle‐Pinkston, S., Tyler, H. C., Dondanville, K. A., Young‐McCaughan, S., Scullin, M. K., Nicholson, K. L., et al. (2020) · Contemporary Clinical Trials · doi:10.1016/j.cct.2020.106186 · Cited by 11
Multi-component Treatment for Posttraumatic Nightmares in Vietnam Veterans: Two Case Studies
Wanner, J. L., Long, M. E., & Teng, E. J. (2010) · Journal of Psychiatric Practice · doi:10.1097/01.pra.0000386910.31817.b5 · Cited by 9
A case of driving phobia treated with dissociative imagery
Williamson, A. (2004) · Contemporary Hypnosis · doi:10.1002/ch.294 · Cited by 7
A Scoping Review of Interventions Targeting the Mental Health of Australian Veterans
Wadham, B., Andrewartha, L., Lawn, S., Onur, İ., & Edney, L. C. (2024) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph21060796 · Cited by 6
Hicks, M., Simonds, L. M., & Morison, L. A. (2024) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.3025 · Cited by 6
Psychotherapy Interventions for Comorbid Sleep Disorders and Posttraumatic Stress Disorder
Pruiksma, K. E., Wachen, J. S., Wardle‐Pinkston, S., & Resick, P. A. (2017) · Springer eBooks · doi:10.1007/978-1-4939-7148-0_24 · Cited by 6
Ochsner, M. S. (2011) · VCU Scholars Compass (Virginia Commonwealth University) · doi:10.25772/d9s2-vq28 · Cited by 6
“Of the few studies with combat veterans published in which follow-up data was collected, low response rate did not appear to be an issue (Lu et al., 2009; Forbes et al., 2003).”
BackgroundResultPost‐traumatic Stress Disorder (PTSD)
Ibbotson, G. (2011) · Wiley eBooks · doi:10.1002/9781119950905.ch26 · Cited by 6
Eye Movement Desensitization and Reprocessing Treatment of Nightmares: A Case Report
Woo, M. (2014) · Journal of EMDR Practice and Research · doi:10.1891/1933-3196.8.3.129 · Cited by 7
O'Neil, M. E., Cheney, T. P., Hsu, F. C., Carlson, K. F., Hart, E. L., Holmes, R. S., Murphy, K. M., Graham, E., Cameron, D. C., Kahler, J., et al. (2020) · doi:10.23970/ahrqepccer235 · Cited by 6
Alliger-Horn, C., Zimmermann, P., Herr, K., Danker-Hopfe, H., & Willmund, G. (2017) · Zeitschrift für Psychiatrie Psychologie und Psychotherapie · doi:10.1024/1661-4747/a000328 · Cited by 4
The vestibulocochlear bases for wartime posttraumatic stress disorder manifestations
Tigno, T. A., Armonda, R. A., Bell, R. S., & Severson, M. A. (2017) · Medical Hypotheses · doi:10.1016/j.mehy.2017.06.027 · Cited by 3
“Imagery Rehearsal Treatment (159, 160, 161) applied for recurring nightmares in PTSD had its beginnings in imagined visualizations and role playing, akin to the use of desensitizing Virtual Reality Exposure Therapy (VRET) used in representative studies for PTSD (162).”
MethodKoninck, J. D., Forest, G., & Lortie‐Lussier, M. (2012) · Médecine du Sommeil · doi:10.1016/j.msom.2012.06.002 · Cited by 3
Cognitive-Behavioral Therapy for Insomnia and Nightmares in PTSD
Belleville, G., & Dubé‐Frenette, M. (2015) · Springer eBooks · doi:10.1007/978-3-319-08613-2_38-1 · Cited by 2
Posttraumatic Stress Disorder: Assessment and Treatment
Kulkarni, M. R., Barrad, A., & Cloître, M. (2014) · Wiley eBooks · doi:10.1002/9781118775349.ch50 · Cited by 2
Ocean, S. E. (2014) · The Mathematics Enthusiast · Cited by 2
Conceptual Framework for Clinical Decision Making in Complementary and Alternative Medicine
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Prolonged Exposure Therapy Following Awareness Under Anesthesia: A Case Study
Levinson, C. A., Rodebaugh, T. L., & Bertelson, A. D. (2012) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2012.02.003 · Cited by 1
“Recent empirical research has developed treatments specifically targeting trauma-related nightmares, using imagery rehearsal (i.e., rescripting a portion of the nightmare) as a therapeutic technique (Forbes et al., 2003; Krakow et al.).”
BackgroundImagery Rehearsal Therapy for PTSD-Related Nightmares
Countryman, A. J., & Leggett, M. K. (2017) · Springer eBooks · doi:10.1007/978-1-4939-7148-0_26 · Cited by 1
Pagel, J. F. (2020) · Springer eBooks · doi:10.1007/978-3-030-55909-0_13 · Cited by 1
Cognitive and Behavioral Interventions for Parasomnias
Nichols, C. D., & Bongiorno, C. M. (2013) · Springer eBooks · doi:10.1007/978-1-4614-7627-6_27 · Cited by 1
Treatment of Nightmares Using Imagery Rehearsal Therapy: A Multiple Baseline Study
Nadorff, M. R. (2012) · The Research Repository @ WVU (West Virginia University) · doi:10.33915/etd.4902 · Cited by 1
“Even Freud, who did a considerable amount of work on dreams, rarely discussed nightmares. In his book The Interpretation of Dreams, Freud only mentions nightmares twice, and neither time did he provide a theory as to why individuals have nightmares (Freud, 2004). Contemporary theorists have put forth ideas about the e…”
BackgroundInfluentialLes rêves dysphoriques chez les enfants : épidémiologie, facteurs de risque et traitement
Simard, V. (2008) · doi:10.71781/19052 · Cited by 1
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“However, most studies focus on adults with “classic” PTSD, with limited research in adolescents or in CPTSD populations [31, 33, 34].”
Elzo, F. A. (2011) · Victoria University Research Repository (Victoria University)
Treating post-traumatic stress disorder-related dreams: what are the options?
Phelps, A. J., & Forbes, D. (2012) · Expert Review of Neurotherapeutics · doi:10.1586/ern.12.110
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Other Issues in Managing the Sleep of Those with Anxiety
Carney, C., & Edinger, J. (2010) · Springer eBooks · doi:10.1007/978-1-4419-1434-7_9
Cognitive-Behavioral Therapy for Insomnia and Nightmares in PTSD
Belleville, G., & Dubé‐Frenette, M. (2016) · Springer eBooks · doi:10.1007/978-3-319-08359-9_38
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Metadata
- Authors
- Forbes, D., Phelps, A. J., McHugh, A. F., Debenham, P., Hopwood, M., & Creamer, M.
- Affiliations
- The University of Melbourne (AU)
- Heidelberg Repatriation Hospital (AU)
- Corresponding author
- Forbes, David
- Venue
- Journal of Traumatic Stress
- Publisher
- Wiley
- Published
- 2003-10
- Volume
- 16
- Issue
- 5
- Pages
- 509-513
- ISSN
- 0894-9867 (ISSN-L)
- 1573-6598
- OpenAlex
- W2017043218
- Cited by
- 104
- References
- 24
- Citations by year
- 2026: 3 · 2025: 2 · 2024: 2 · 2023: 1 · 2022: 1 · 2021: 1 · 2020: 5 · 2019: 3 · 2018: 3 · 2017: 7 · 2016: 1 · 2015: 3 · 2014: 6 · 2013: 7 · 2012: 12
- FWCI
- 4.55
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Traumatic Stress (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- imagery rehearsal therapy, posttraumatic nightmares, combat-related posttraumatic stress disorder, veterans, Vietnam War veterans, long-term treatment outcomes, depression, anxiety, symptom maintenance
- MeSH terms
- Australia, Chronic Disease, Dreams, Follow-Up Studies, Humans, Male, Middle Aged, Severity of Illness Index, Stress Disorders, Post-Traumatic, Treatment Outcome, Imagery, Psychotherapy
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