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originalcontribution imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder a randomized controlled trial barry krakow md context chronic nightmares occur frequently in patients with ...

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                          ORIGINALCONTRIBUTION
                  Imagery Rehearsal Therapy for Chronic
                  Nightmares in Sexual Assault Survivors
                  With Posttraumatic Stress Disorder
                  A Randomized Controlled Trial
                  Barry Krakow, MD                                      Context Chronic nightmares occur frequently in patients with posttraumatic stress
                  Michael Hollifield, MD                                disorder (PTSD) but are not usually a primary target of treatment.
                  Lisa Johnston, MA, MPH                                Objective Todetermineiftreatingchronicnightmareswithimageryrehearsaltherapy
                  Mary Koss, PhD                                        (IRT) reduces the frequency of disturbing dreams, improves sleep quality, and de-
                                                                        creases PTSD symptom severity.
                  RonSchrader, PhD                                      Design, Setting, and Participants Randomized controlled trial conducted from
                  Teddy D. Warner, PhD                                  1995to1999among168womeninNewMexico;95%hadmoderate-to-severePTSD,
                  DanTandberg, MD                                       97%hadexperiencedrapeorothersexualassault,77%reportedlife-threateningsexual
                                                                        assault, and 58% reported repeated exposure to sexual abuse in childhood or ado-
                  John Lauriello, MD                                    lescence.
                  Leslie McBride, BA                                    Intervention Participants were randomized to receive treatment (n=88) or to the
                  Lisa Cutchen, MA                                      wait-list control group (n=80). The treatment group received IRT in 3 sessions; con-
                                                                        trols received no additional intervention, but continued any ongoing treatment.
                  Diana Cheng, MA                                       MainOutcomeMeasures ScoresontheNightmareFrequencyQuestionnaire(NFQ),
                  ShawnEmmons,PhD                                       Pittsburgh Sleep Quality Index (PSQI), PTSD Symptom Scale (PSS), and Clinician-
                  Anne Germain, MPs                                     Administered PTSD Scale (CAPS) at 3- and 6-month follow-up.
                  Dominic Melendrez, PSG-T                              Results Atotalof114participantscompletedfollow-upat3and/or6months.Com-
                                                                        paring baseline to follow-up (n=97-114), treatment significantly reduced nights per
                  Diane Sandoval, BS                                    weekwithnightmares(Cohend=1.24;P.001)andnumberofnightmaresperweek
                  Holly Prince, MA                                      (Cohend=0.85;P.001)ontheNFQandimprovedsleep(onthePSQI,Cohend=0.67;
                                                                        P.001)andPTSDsymptoms(onthePSS,Cohend=1.00;P.001andontheCAPS,
                                IELSEN AND ZADRA1 RE-                   Cohend=1.53;P.001).Controlparticipantsshowedsmall,nonsignificantimprove-
                                centlyestimatedthat“4to8%               ments for the same measures (mean Cohen d=0.21). In a 3-point analysis (n=66-
                                of the general population               77), improvementsoccurredinthetreatmentgroupat3-monthfollow-up(treatment
                  Nhavea‘currentproblem’with                            vscontrolgroup,Cohend=1.15vs0.07fornightsperweekwithnightmares;0.95vs
                  nightmares.” Frequent nightmares are                  −0.06 for nightmares per week; 0.77 vs 0.31 on the PSQI, and 1.06 vs 0.31 on the
                                                                        PSS)andweresustainedwithoutfurtherinterventionorcontactbetween3and6months.
                  alsoreportedindepression,2schizophre-                 Anintent-to-treat analysis (n=168) confirmed significant differences between treat-
                  nia-spectrum disorders,3 and in post-                 mentandcontrol groups for nightmares, sleep, and PTSD (all P.02) with moderate
                  traumaticstressdisorder(PTSD)where                    effectsizesfortreatment(meanCohend=0.60)andsmalleffectsizesforcontrols(mean
                  a prevalence of 60% has been docu-                    Cohend=0.14).Posttraumatic stress symptoms decreased by at least 1 level of clini-
                             4                                          cal severity in 65% of the treatment group compared with symptoms worsening or
                  mented. Paradoxically, The Interna-                                                               2 =12.80; P.001).
                                                              5         not changing in 69% of controls (1
                  tionalClassificationofSleepDisorders lists            Conclusions Imageryrehearsaltherapyisabrief,well-toleratedtreatmentthatap-
                  a prevalence of “perhaps 1%,” whereas                 pearstodecreasechronicnightmares,improvesleepquality,anddecreasePTSDsymp-
                  the Diagnostic and Statistical Manual of              tomseverity.
                  MentalDisorders,FourthEdition,TextRe-                 JAMA.2001;286:537-545                                                                    www.jama.com
                  vision(DSM-IV-TR)mentionsthatatleast
                                                                        AuthoraffiliationsandFinancialDisclosuresarelisted    Krakow, MD,Sleep&HumanHealthInstitute,4775
                  See also p 584.                                       at the end of this article.                           Indian School Rd NE, Suite 305, Albuquerque, NM
                                                                        Corresponding Author and Reprints: Barry              87110 (e-mail: bkrakow@salud.unm.edu).
                  ©2001AmericanMedicalAssociation. All rights reserved.                                                (Reprinted) JAMA, August 1, 2001—Vol 286, No. 5      537
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               IMAGERYREHEARSALTHERAPY
                                                          ports have appeared since25                scription of the study, participants pro-
               3%ofyoungadultsreportfrequentnight-                                    ; most nota-
               mares,butconcludesthat“actualpreva-        bly, Marks26 theorized that rehearsal of   vided oral and written consent. Per-
               lence of Nightmare Disorder is un-         nightmares provides therapeutic ben-       sonal interviews and psychometric
                       6
               known.” Thesedisparitiesinprevalence       efits through“exposure,abreaction,and      instruments were offered to 203 poten-
                                                                              27                     tial participants. At intake, 79% of par-
               estimates occur because nightmareepi-      mastery,”butBishay suggestedthatex-
               demiological research usually surveys      posure and abreaction were secondary       ticipants were concurrently receiving
               disturbingdreamfrequencywithoutin-         to mastery because he observed that        psychotherapy (primarily counseling)
                                                     7-9
               quiring about comorbid conditions,         changingthestorylineofthedisturbing        and/or psychotropic medications (pri-
               whereastheDSM-IV-TRstatesthatnight-        dream was more effective for the pa-       marilytricyclicantidepressantsorselec-
               maresoccurringwithanotherpsychiat-         tientthanrehearsaloftheoriginaldream.      tive serotonin reuptake inhibitors).
               ric disorder precludes a nightmare dis-    Early in our work with nightmare suf-
                                   6                                                                 Randomization and
               order diagnosis. This latter and           ferers, weobservedthatmasterywaspiv-
               prevailing view of disturbing dreams       otal in the resolution of chronic night-   Blinding Procedures
               holds that nightmares are secondary to     mares. Kellner et al28 raised the issue of To mask treatment assignment, pa-
               another disorder, such as anxiety or       whetherIRTwouldbeeffectiveintreat-         tients mailed back a postcard after in-
               PTSD.5,6,10Whilethisviewhasnosologi-       ing severe, chronic nightmares in pa-      take to complete entry into the proto-
               cal support, it suggests that nightmares   tients with comorbid psychiatric disor-    col. The postcard’s time and date were
               are not a distinctly treatable condition   ders, such as PTSD, particularly rape      loggedintoacomputerandenteredinto
               andthatremissionoccursonlythrough          survivors who frequently suffer severe     apreviouslygeneratedlistofnumbers
                                                                                     4,29 We also
               treatment of the primary disorder. For     nightmare disturbances.                    thatrandomlyassignedparticipantsto
               example, if nightmares were attributed     speculatedthatsexualassaultsurvivors       treatmentandcontrolgroups.Allnum-
               to posttraumatic stress, it seems logical  mightbereceptivetoIRTbecauseofits          bersandgroupassignmentsweregen-
               to focus treatment efforts on PTSD,        focus on dreams and sleep and its de-      eratedatthestartoftheprotocol.Ran-
               whichoughttoreducebaddreams,dis-           emphasis on exposure to past trau-         domizationof168womenproduced2
               tress, and impairment.11                   matic events.                              groups: treatment (n=88) and wait-
                                                                                                                             2
                 Incontrast,evidenceshowsthatdis-            Wetherefore conducted a prospec-        list control (n=80) ( =0.38, P=.54)
               turbing dreams are associated with         tive randomizedcontrolledtrialofIRT        (FIGURE1).Of35womenwhodidnot
                                     12-14
               psychologicaldistress     andsleepim-      in a sample predominantly consisting       participate,29didnotcompletefullin-
                         15,16
               pairment.     Moderate-to-largecorre-      of sexual assault survivors with PTSD      takepacketsand6didnotreturnpost-
               lations between nightmares and anxi-       to assess treatment effects of targeted    cards.Duetothewait-listdesign,blind-
               ety, depression, and PTSD have been        nightmare therapy on nightmares,           ing was not possible for delivery of
                         13,14,17
               reported.        Nightmares disrupt        sleep,andposttraumaticstress.Wehy-         treatment.Tolimitexternalbias,blind-
               sleep, producing conditioning pat-         pothesized that sexual assault survi-      ingoccurredat3pointsofdatacollec-
               terns similar to classic psychophysi-      vors treated with IRT would report         tion: (1) at intake, group assignment
               ological insomnia along with a spe-        fewernightmares,improvedsleepqual-         had not been established; (2) at
               cific complaint of “fear of going to       ity, and decreased distress compared       3-month follow-up, questionnaires
                      12,15,16
               sleep.”     Prospectivetreatmentstud-      with a wait-list control group.            werecompletedthroughthemail;and
               ies of brief cognitive-behavioral tech-    METHODS                                    (3) at 6-month follow-up, interview-
               niques, including desensitization and                                                 ers were unaware of group status.
               imagery rehearsal, which solely tar-       Study Population
               geted disturbing dreams in nightmare       ThestudywasapprovedbytheUniver-            Measurements
               sufferers without comorbid psychiat-       sity of NewMexicoHealthSciencesCen-        Primary outcome measures consisted
               ric disorders, demonstrated large re-      ter institutional review board. Eligible   of 5 variables assessed by self-report
               ductions in nightmares.18-22 In some       participants were female sexual assault    withvalidated,standardizedquestion-
               studies,decreasednightmareswereas-         survivors, 18 years or older, with self-   nairescompletedatintakeandfollow-
                                               20,21
               sociatedwithdecreasedanxiety        and    reportednightmares,insomnia,andpost-       ups. The Nightmare Frequency Ques-
                                       22
               improvementsinsleep. Inaprelimi-           traumaticstresssymptomscoupledwith         tionnaire (NFQ)assesses“nightswith
                                                                                   6
               naryreportonnightmaretreatmentin           acriterionAtraumalink. Womenwith           nightmares” per unit of time (eg, per
               PTSDpatients,disturbingdreamsand           acute intoxication, withdrawal, or psy-    week,permonth)andactual“number
               posttraumatic stress severity de-          chosiswereexcluded.Participantswere        of nightmares.” Test-retest reliability
               creasedandsleepqualityimprovedwith         recruited from media efforts (35% of       produced weighted  of 0.85 to 0.90,
                                                  23
               imagery rehearsal therapy (IRT).           sample),mentalhealththerapistsandfa-       and concurrent validity was estab-
                      24
                 Wile reportedthefirstcaseseriesin        cilities (36%),rapecrisiscenters(17%),     lished with a mean correlation coeffi-
               whichanimagerytechniquewasusedin           andotherresources(10%)from1995to           cient of 0.38 (r=0.28-0.49) with mea-
               thetreatmentofnightmares.Severalre-        1999. After being given a complete de-     sures of anxiety, depression, and
               538 JAMA, August 1, 2001—Vol 286, No. 5 (Reprinted)                     ©2001AmericanMedicalAssociation. All rights reserved.
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                                                                                                                                                            IMAGERYREHEARSALTHERAPY
                               17                                                   restructuring paradigm. Treatment as-
                     PTSD. The Pittsburgh Sleep Quality                                                                                            Figure 1. Study Flow Chart
                     Index(PSQI)assessessleepqualityand                             sumptionsconveyedtothepatientswere
                     disturbances during the past month                             asfollows:(1)nightmaresmaybecaused                                              203 Participants Enrolled
                     basedon7componentscoresforsleep                                byuncontrollableandtraumaticevents,
                     quality, latency, duration, efficiency,                        yet may serve a beneficial purpose im-                                          35 Lost to Follow-up
                     disturbance, medication use, and day-                          mediately following trauma by provid-                                              29 Did Not Complete
                                                                                                                                                                           Intake Packets
                     time dysfunction that sum to a global                          inginformationandemotionalprocess-                                                   6 Did Not Return
                     score (range, 0-21).30 The Clinician-                          ing;(2)nightmarespersistingformonths                                                   Entry Request
                     AdministeredPTSDScale(CAPS)mea-                                maynolongerserveusefulpurposesand                                                   168 Randomized
                     suresfrequencyandintensityofPTSD-                              maybeviewedmorepragmaticallyasa
                     related symptoms for the preceding                             sleep disorder; (3) nightmares may be                            80 Assigned to Wait-List     88 Assigned to Cognitive
                     month (range, 0-136).31 The PTSD                               successfullycontrolledbytargetingthem                               Control Group                 Imagery Treatment
                     SymptomScale (PSS) measures PTSD                               ashabitsorlearnedbehaviors;(4)work-                                                               Group
                     symptomsaccordingtoDiagnosticand                               ing with waking imagery influences                               20 Withdrawn                 22 Withdrawn Before
                     Statistical Manual of Mental Disorders,                        nightmaresbecausethingsthoughtabout                                 16 Lost to Follow-up          Completing Treatment
                     Revised Third Edition (DSM-III-R) cri-                         during the day are related to things                                  2 Actively Withdrew         15 Lost to Follow-up
                                                                                                                                                          2 Moved out of               4 Actively Withdrew
                     teria to evaluate the severity of intru-                       dreamedaboutatnight;(5)nightmares                                       State                      3 Moved out of State
                     sion, avoidance, and arousal symp-                             can be changed into positive, new im-                                                         66 Completed Treatment
                     toms and sums these scales for total                           agery; and (6) rehearsing new imagery                            60 Completed a 3- and/
                                                                                                                                                        or 6-mo Follow-up             12 No Posttreatment
                     severity in the preceding 2-week pe-                           (“newdream”)whileawakereducesor                                     52 Completed 3-mo                Follow-up
                                                  32                                eliminates nightmares, without requir-                                  Follow-up                 54 Completed a
                     riod (range, 0-51).             Higher scores re-                                                                                  53 Completed 6-mo                3- and/or 6-mo
                     flect greater severity on each measure.                        ing changes on each and every night-                                    Follow-up                    Follow-up
                         Secondarymeasuresincludedthefol-                           mare. Groups of 4 to 8 women were                                                                    44 Completed
                                                                                                                                                                                             3-mo Follow-up
                     lowing:NightmareEffectsSurvey(NES)                             formed,andtreatmentwasprovidedon                                                                     46 Completed
                     (impairment associated with night-                             average every month to every other                                                                       6-mo Follow-up
                     mares),23NightmareDistressQuestion-                            monthbasedonrecruitment.                                         60 Included in End Point     54 Included in End Point
                     naire (NDQ) (distress associated with                              In the first session of IRT, partici-                            Analysis                     Analysis
                                         33                                                                                                          41 Included in 3-Point       36 Included in 3-Point
                     nightmares),           Pittsburgh Sleep Qual-                  pantsareencouragedtoexamine2con-                                     Analysis                     Analysis
                     ity Index-Addendum(PSQI-A)(PTSD-                               trasting views of nightmares: night-                             80 Included in Intent-to-    88 Included in Intent-to-
                                                             30                     mares as a function only of traumatic                                Treat Analysis               Treat Analysis
                     related sleep symptoms),                    Hamilton
                     AnxietyandDepressionscales,34,35Shee-                          exposure vs nightmares as a function
                     han Disability Inventory (SDI) (daily                          of both traumaandlearnedbehaviors.                             bothinherwrittenattemptand,ifap-
                     functioning),36andtheSF-36(physical                            Participants are asked to explore the                          plicable,duringtheactualrehearsalpro-
                     andmentalhealthfunctioning).37Infor-                           possibility that although nightmares                           cess. After this initial exercise, partici-
                     mation was also collected on baseline                          maybetrauma-induced,theymayalso                                pantsareencouragedtonotwritedown
                     historyofpasttraumaticeventsandbase-                           behabit-sustained.Attheendofthefirst                           the old nightmare or the changed ver-
                     line and follow-up use of antidepres-                          session, participants practice pleasant                        sion but to establish the process men-
                     sants,anxiolytic/hypnotics,andconcur-                          imagery exercises, learn cognitive-                            tally. They are instructed to rehearse a
                     rent psychotherapy. The NFQ, PSQI,                             behavioral tools for dealing with un-                          newdreamforatleast5to20minutes
                     andPSSmeasureswereadministeredat                               pleasantimagesthatmightemerge,and                              perdaybutnevertoworkonmorethan
                     3 points in the study; all other mea-                          are asked to practice pleasant imag-                           2 distinct “new dreams” during each
                     sureswereadministeredatbaselineand                             ery. At the second session, imagery                            week.Descriptionsoftraumaticexpe-
                     6-monthfollow-up.                                              practice is discussed and any difficul-                        riencesandtraumaticcontentofnight-
                                                                                    ties addressed.Then,participantslearn                          maresarediscouragedthroughoutthe
                     Treatment                                                      how to use IRT on a single, self-                              program in a carefully designed at-
                     Treatment consisted of 3 sessions (two                         selected nightmare. The participant                            tempttominimizedirectexposure.To
                     3-hoursessionsspaced1weekapartwith                             writesdownherdisturbingdream,then                              facilitate this approach,participantsare
                     a1-hourfollow-up3weekslater)using                              peramodeldevisedbyNeidhardtetal,21                             instructed to work first with a night-
                     a cognitive-imagery treatment,23 pre-                          is instructedto“changethenightmare                             mare of lesser intensity and, if pos-
                     sented in groups (led primarily by B.K.                        anyway you wish” and to write down                             sible, onethatdoesnotseemlikea“re-
                     and a few by L.C. [which were ob-                              the changed dream. Afterward, each                             play” or a “reenactment” of a trauma.
                     served and supervised by B.K.]). The                           participantusesimagerytorehearseher                            In3weeks,thegroupmeetsfora1-hour
                     treatment protocol followed a manual                           own“newdream”scenariofor10to15                                 session to discuss progress, share ex-
                     and focused on nightmares within the                           minutes.Next,shebrieflydescribesher                            periences, and ask questions about
                     frameworkofanimageryandcognitive                               oldnightmareandhowshechangedit,                                nightmares, sleep, and PTSD and how
                     ©2001AmericanMedicalAssociation. All rights reserved.                                                                (Reprinted) JAMA, August 1, 2001—Vol 286, No. 5                539
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              IMAGERYREHEARSALTHERAPY
              IRT might be useful for other symp-      peated measures ANOVAwasthepri-          formainoutcomevariableswerefound
              toms in addition to nightmares.          maryanalyticprocedurereportedinthis      (TABLE2).Nosignificantdifferencesbe-
                                                       study. Treatment efficacy analyses as-   tween groups for concurrent psycho-
              Follow-up                                sessed the following: (1) end point      therapyandanxiolytic/hypnoticuseat
              Treatment and control participants       (n=97-114, changes from baseline to      baselineweredetected,butcontrolnon-
              weremailedafollow-uppacketofques-        endpointbasedonlastfollow-up,3or         completers’ concurrent use of antide-
              tionnaires at 3 months and invited to    6month,observation carried-forward       pressantswassignificantlylessthanuse
              apersonalinterviewat6months.Ofthe        analysis); (2) 3 points (n=66-77,        by other groups at baseline (P=.03)
              168randomizedparticipants,96com-         changes from baseline to 3-month to      (TABLE 3). No significant differences
              pleted3-monthfollow-upsbymail,and        6-month follow-up); and, (3) intent-     werefoundforfrequencyoftraumatic
              99completedthe6-monthfollow-ups          to-treat(n=168,changesinbaselineto       exposures documented at baseline in-
              inperson.Intotal,114individualscom-      last observation,includingbaseline,car-  terviews (Table 3).
              pletedatleast1follow-up,and77par-        ried-forward analysis, ie, all random-      Eighty-threepercentofparticipants
              ticipants completed both follow-ups.     ized individuals).                       reported clinically meaningful post-
              Most noncompleters were lost to fol-       To test whether moderator vari-        traumatic stress severity on the CAPS
              low-up early in the program, usually     ables influenced treatment effects, re-  (score65),31and95%reportedmod-
              within1monthofrandomization.How-         peated-measures ANOVAs were con-         erate or worse posttraumatic stress se-
              ever, 12 completedtreatmentsessions      ductedonthemainoutcomevariables          verity on the PSS (score 11), all of
              and then were lost to follow-up (Fig-    using each potential moderator as an     whommetDSM-III-Rdiagnosticcrite-
              ure 1). Contact with control partici-    additional between-subjects indepen-     ria for PTSD.32Theremaining5%(n=8)
              pants was limited to brief telephone     dent variable in a treatmenttime       experiencedmildposttraumaticstress.
              calls and letters to remind them of fu-  moderator design. The moderators         Nightmare chronicity was not signifi-
              tureappointments.Allparticipantswere     tested were antidepressant use, anxio-   cantly different between the 2 groups
              asked to complete a 5-item question-     lytic/hypnoticuse,concurrentpsycho-      (treatment: mean [SD] of 21.8 [15.3]
              naireaboutpotentialsuicidalityatbase-    therapy, number of potentially life-     years vs control: 19.3 [13.7] years).
              line and follow-ups. A few patients re-  threatening sexual assaults (“high       Ninety percent experienced sexual,
              portedacutedistressandwerereferred       magnitude”), or repeated exposure to     physical, or emotional abuse as chil-
              forcrisisintervention.Allcontrolscon-    sexual abuse. Repeated measures          dren, with sexual abuse the most fre-
              tinued any treatment they were al-       ANOVAswerealsoconductedonsec-            quentlyreported.Fifty-eightpercentre-
              readyreceivingandwereofferedtreat-       ondarymeasuresbetweenbaselineand         ported repeated exposure to sexual
              ment at no charge on completion of       6 months. All tests used the .05 level   abuseforanaverageperiodof8years,
              their 6-month wait-list period.          ofsignificanceandeffectsizeswerere-      among whom 72% were 10 years old
                                                       ported as Cohen d, the standardized      or younger when this abuse first oc-
              Data Analysis                            meandifference.                          curred. Seventy-seven percent re-
              Ethnicity, marital status, income, and   RESULTS                                  ported high-magnitude sexual as-
              educationwereeachcondensedinto2                                                   saults during their lifetime, among
              categories due to sparse cells. Com-     Demographic and Clinical                 whom48%experienced2ormoresuch
              parison of baseline data on main out-    Characteristics                          events.Threeparticipantswhowereex-
              comemeasures for nightmares, sleep,      A total of 168 participants were ran-    posed to violent, nonsexual assaults
              andPTSDanddemographicsfortreat-          domized into control and treatment       wereretainedintheprotocolandanaly-
              mentvscontrolgroupsbycompleters          groups and were compared based on        sis because their baseline data were
              (at end point: completed either 3- or    follow-up status: control completers     similar to the sexual assault survivors.
              6-month follow-up) and noncompl-         (n=60),treatmentcompleters(n=54),
              eters were analyzed using analysis of    control noncompleters (n=20), and        Treatment Efficacy
              variance (ANOVA) and 2 test. Al-        treatment noncompleters (n=34).          Treatmenttime interaction effects
              thoughpatientswereindividuallyran-       Therewasnosignificantdifferencefor       were found with a substantial de-
              domized, treatment was conducted in      lost to follow-up rates between con-     crease in nightmares, sleep, and PTSD
              smallgroups,andthereforeeffectsmay       trol and treatment noncompleters         scores at end point for the treatment
              have correlated with group member-       (Fisher exact test, P=.07). No signifi-  group but only small changes, on av-
              ship; thus, grouping effects on treat-   cantbaselinedifferenceswerefoundbe-      erage,forthecontrolgroup(TABLE4).
              ment for all main outcome variables      tweengroupswiththeexceptionofage         Treatment group improvements were
              wereinitiallyanalyzedwithrandomef-       (P=.01), whereby control noncom-         large for nights per week (d=1.24),
                              38
              fects regression  usingPROCMIXED pleters were younger than treatment              nightmares per week (d=0.85), PSQI
                     39
              in SAS.   Because no grouping effects    completers (TABLE 1). No significant     (d=0.67), PSS (d=1.00), and CAPS
              approachedsignificance(allP.90),re-     baselinedifferencesamongthe4groups       (d=1.53).Forthemainoutcomemea-
              540 JAMA, August 1, 2001—Vol 286, No. 5 (Reprinted)                  ©2001AmericanMedicalAssociation. All rights reserved.
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...Originalcontribution imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder a randomized controlled trial barry krakow md context occur frequently patients michael hollifield ptsd but are not usually primary target of treatment lisa johnston ma mph objective todetermineiftreatingchronicnightmareswithimageryrehearsaltherapy mary koss phd irt reduces the frequency disturbing dreams improves sleep quality and de creases symptom severity ronschrader design setting participants conducted from teddy d warner toamongwomeninnewmexico hadmoderate to severeptsd dantandberg hadexperiencedrapeorothersexualassault reportedlife threateningsexual reported repeated exposure abuse childhood or ado john lauriello lescence leslie mcbride ba intervention were receive n cutchen wait list control group received sessions con trols no additional continued any ongoing diana cheng mainoutcomemeasures scoresonthenightmarefrequencyquestionnaire nfq shawnemm...

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