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Sleep Disorders - The Use Of Imagery Techniques In Post-Traumatic Stress Disorder

Individuals who suffer from sleep disorders, particularly nightmares, may find themselves in a state of extreme distress and require specialized treatment.

This is especially true if the individual has been diagnosed with post-traumatic stress disorder (PTSD).

Nightmares are among the most typical signs of traumatized people, and they also affect 8% of the general population.

Imagery Rehearsal Therapy (IRT), an empirically supported approach, appears to be the most effective method to date for treating traumatic sleep disturbances.

This article examines the literature on the topic in order to describe the prevalence and effects of nightmares in PTSD, show how IRT might be effective in treating them, and explore its clinical applications.

What Is Post-Traumatic Disorder?

After experiencing, witnessing, or being threatened by a traumatic event, a person may experience post-traumatic stress disorder, which is a psychiatric disorder. Natural disasters, accidents, violent crime, or sexual assault are examples of the kinds of incidents that can cause PTSD.

Post-traumatic stress disorder (PTSD) is a mental health condition included in DSM-5's "Trauma and Stressor Related Disorders" category. PTSD is characterized by a wide array of symptoms after experiencing "death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence"

Flashbacks and nightmares are common symptoms of PTSD, along with feelings of anxiety, sadness, and anger. You may also avoid situations that trigger unpleasant memories. You might think it's more difficult than usual to maintain your relationships with others or your routines at work or school.

Be aware that PTSD is a mental health condition that can be diagnosed and treated rather than a sign of weakness. You or a loved one can start to feel better with the assistance of a mental health professional.

A black man wearing a blue t-shirt laying awake on his bed while being covered with a white duvet
A black man wearing a blue t-shirt laying awake on his bed while being covered with a white duvet

Sleep Disorders And Nightmares In PTSD

Post-traumatic sleep disorders seem to be prominent. "O memory, mortal enemy of my rest!" wrote Cervantes, encapsulating, perhaps unconsciously, the struggle of those who, after a traumatic experience, are haunted by intrusive images during wake and sleep.

Numerous studies show a link between traumatic events and sleep problems, as well as upsetting nightmares. These consequences are a typical response to a traumatic event, so the DSM lists nightmares in Cluster B (re-experiencing) and difficulty falling or staying asleep in Cluster D (arousal alterations).

Kat et al. conducted 143 interviews with survivors of the Hanshin earthquake in 1995 to understand the impact the event had on them. Sleep disturbances were the most common symptom, affecting 63% of the sample 3 weeks after the event and 46% 8 weeks later. Similarly, Goldstein et al. and Kuch et al. have noted the prevalence of these symptoms in trauma victims. Sleep problems were discovered in 97% of soldiers in combat and 95% of Holocaust survivors. In addition, nightmares were the biggest issue for both the former (94%) and the latter (83%).

Imagery Rehearsal Therapy For Nightmares

In light of the previous paragraphs' data, it's important to develop a specific approach for treating sleep disorders–especially nightmares–in PTSD patients. Many cognitive-behavioral authors suggest working with "mental images." According to them, these techniques could be used to treat nightmares related to PTSD because they allow the clinician to (a) directly access the nightmare's content and emotions, (b) identify and modify negative cognitions related to the traumatic event, and (c) reduce post-traumatic symptoms. Both Krakow et al. and Davis and Wright identified techniques that allow more effective rescripting.

Imagery Rehearsal Therapy (IRT) was developed by Ian Marks in 1967 and perfected by Barry James Krakow and other psychotherapists interested in its use in treating post-traumatic symptoms. Based on the work of Bootzin, Nicassio, and Howoritz, this procedure considers nightmares a "learned" sleep disorder caused by mental image distortions. From this perspective, nightmares are no longer considered a post-traumatic symptom treatable only by trauma-focused therapy. They become a distinct phenomenon that, while originally related to the trauma, tends to become chronic and have a "life of its own," aggravating PTSD's overall symptomatology.

The duration, frequency, and number of IRT sessions depend on the clinical case. The intervention is divided into the following sections:


The clinician gives the patient and family members (if needed) detailed information about dreams and trauma. The patient is also instructed on proper sleep hygiene and dysfunctional behaviors that cause insomnia.


In this phase, the patient "learns" to cope with nightmares by developing pleasant mental images. Krakow suggests using color, shapes, and movement as "basic tools" for constructing positive mental images (visual sense); daydreaming, which can encourage the emergence of positive images; and self-talk, in which the patient associates a positive word with a pleasant image or story.

A little girl laying on a bed with white bed sheets with both hands covering her face
A little girl laying on a bed with white bed sheets with both hands covering her face

Selecting The Disturbing Nightmare

Once the patient has learned to work with mental images and manage dissociative responses, the target nightmare is chosen. This is usually the most emotional or frequent (these two often coincide). In other cases, the patient starts with a less intense nightmare so as not to feel overwhelmed.

Re-Evocation Of The Selected Nightmare

The patient is given instructions to write down their nightmare of choice and is encouraged to make notes on all of the specifics.

Nightmare Rescripting

Using phase two skills, the patient can now change his nightmare. In this stage, which is at the heart of IRT, patients are offered the chance to change their nightmare's theme, plot, ending, or any other part they believe could help them in the rescripting. The majority of people (58%) created alternative endings, according to Harb et al.


The patient is asked to mentally rehearse the rescripted nightmare for 10–20 min a day (preferably before bed) until the nightmares become less frequent. For this to happen, they must only repeat the new script, not the original nightmare.

Clinical Applications With Adult Patients

War Veterans

IRT appears to be particularly effective in reducing nightmares in PTSD-affected war veterans in the adult clinical population. To meet the needs of veterans, Long et al. used a variant of the initial model, IRET. The authors tested the rescripting treatment on 37 US veterans with PTSD and chronic post-traumatic nightmares (10 years). 15.2% of the 33 patients who finished the therapy claimed not to have experienced any upsetting nightmares since. 30.3% reported sleeping 6 hours or more per night. Also, 30 of 33 patients (90.9%) reported moderate improvements in sleep disturbances.

A little boy laying with his eyes open on a bed covered with a white duvet with his hand on an analog alarm clock
A little boy laying with his eyes open on a bed covered with a white duvet with his hand on an analog alarm clock

Victims Of Sexual Abuse

IRT is also effective in reducing nightmares in sexually abused subjects, which can lead to PTSD. Davis and Wright found that abuse victims frequently experience sleep disturbances and nightmares, which can contribute to PTSD and depression. Cognitive Behavioral Therapy (CBT) rarely directly addresses this issue.

According to Belleville et al., CBT improves sleep-related problems, but they often return 6 months after treatment ends. Therefore, the authors recommend developing guidelines and standardized procedures for treating sleep disorders in PTSD patients. They compared the effects of IRT on sleep disturbances (such as insomnia and nightmares), PTSD symptoms, general functioning, and quality of life to CBT alone in a randomized controlled trial.

42 adults with a history of sexual abuse and PTSD were randomly assigned to IRT+CBT or CBT alone. Before starting CBT, women in the experimental group had IRT on their worst nightmare for 5 weeks. All participants received 15 CBT sessions. Even though both groups showed a significant–and similar–decrease in PTSD symptoms, associated with an improvement in general functioning and quality of life, the IRT group showed a greater improvement in sleep quality and a greater decrease in nightmares.

People Also Ask

How Do You Deal With Nightmares With PTSD?

Make sure your bedroom isn't too cold or too hot; start a nightly relaxation routine; make sure light isn't keeping you from sleeping deeply; exercise daily; talk about your dreams, and engage in Image Rehearsal Therapy (IRT).

How Do You Treat PTSD Insomnia?

PTSD-related insomnia is often treated with sedative antidepressants (e.g., mirtazapine, doxepin, trimipramine, and amitriptyline) or sedative atypical antipsychotics (e.g., quetiapine).

How Do You Treat Nightmares And Insomnia?

The American Academy of Sleep Medicine suggests using both pharmacological therapy and behavioral therapy to treat adult nightmare disorders.

Are Nightmares A Symptom Of PTSD?

Even though not everyone who experiences recurrent nightmares is afflicted with a mental health condition, PTSD patients frequently report having these nightmares. According to estimates, fewer than 10% of trauma victims experience PTSD.


The most effective treatments for sleep disorders in PTSD patients involve imagery rescripting. These techniques allow clinicians to quickly identify and modify trauma-related negative beliefs without overwhelming patients.

Rescripting-based therapy may change the effective properties of a nightmare by altering its meaning and influencing the patient's ability to control distressing nightmare images. This is important because in sleep disorders and nightmares, dreams are marked by a lack of self-efficacy, powerlessness, and uncontrollability. IR helps patients express unmet needs and inhibitions.

Today's treatment for nightmares is Imagery Rehearsal Therapy (IRT). This method combines psychoeducation with exposure and imagery rescripting to treat adults, children, and adolescents.

About The Authors

Suleman Shah

Suleman Shah - Suleman Shah is a researcher and freelance writer. As a researcher, he has worked with MNS University of Agriculture, Multan (Pakistan) and Texas A & M University (USA). He regularly writes science articles and blogs for science news website immersse.com and open access publishers OA Publishing London and Scientific Times. He loves to keep himself updated on scientific developments and convert these developments into everyday language to update the readers about the developments in the scientific era. His primary research focus is Plant sciences, and he contributed to this field by publishing his research in scientific journals and presenting his work at many Conferences. Shah graduated from the University of Agriculture Faisalabad (Pakistan) and started his professional carrier with Jaffer Agro Services and later with the Agriculture Department of the Government of Pakistan. His research interest compelled and attracted him to proceed with his carrier in Plant sciences research. So, he started his Ph.D. in Soil Science at MNS University of Agriculture Multan (Pakistan). Later, he started working as a visiting scholar with Texas A&M University (USA). Shah’s experience with big Open Excess publishers like Springers, Frontiers, MDPI, etc., testified to his belief in Open Access as a barrier-removing mechanism between researchers and the readers of their research. Shah believes that Open Access is revolutionizing the publication process and benefitting research in all fields.

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