1222 Does Creativity & “Dose” Enhance Outcomes in Imagery Rehearsal Therapy? A Case of Successful IRT

A 70-year-old man with Nightmare Disorder, longstanding depression, and OSA (using CPAP) who was skeptical about Imagery Rehearsal Therapy (IRT) self-initiated highly detailed, media-enhanced methods for pleasant guided imagery and nightmare re-scripting, including written narratives, voice recordings, and a movie of his re-scripted nightmare with pictures set to music, listening to recordings 2-3 times daily. At week 15, nightmare frequency dropped from 2.0 to 0.25 per night, sleep quality improved from 1.9/5 to 3/5, and insomnia severity decreased from moderately severe to subthreshold. Mood remained stable with mild depression. The case suggests that enhanced self-efficacy through detailed imagery may boost IRT's effectiveness.

Study at a glance

Abstract

Imagery Rehearsal Therapy (IRT) is an efficacious treatment for Nightmare Disorder. In IRT, patients practice pleasant guided imagery techniques, then use these skills to re-script recurring nightmares, which lowers the frequency and intensity of overall nightmare activity. However, the most efficacious methods and dosage of guided imagery and nightmare re-scripting is undetermined. The patient was a 70-year-old male with Nightmare Disorder. Patient denied any precipitating event or trauma associated with nightmare onset. He has a longstanding history of depression and OSA (uses CPAP). He was taking Seroquel, which reduced severity of nightmares but not frequency. Trials of other medications for nightmares had failed (including prazosin, Depakote, and trazodone). Patient presented as highly distressed, exhibited distrust towards medical providers, and was skeptical about the effectiveness of IRT. Despite his skepticism, patient self-initiated very detailed and media-enhanced methods for pleasant guided imagery and nightmare re-scripting, including written narratives, voice recordings, and created a movie of his re-scripted nightmare with pictures set to music. He listened to the recordings 2-3x/day. Themes of nightmares included lack of mastery over problems; patient’s re-scripted dreams put him back in control of frightening scenarios. Nightmare logs at baseline showed sleep quality=1.9/5; average=2.0 nightmares/night; average intensity= 6.2/10. At week 15 of treatment, sleep quality=3/5; nightmares/night average=0.25; average intensity=6/10. Sleep disturbance also improved (ISI=18-moderately severe clinical insomnia to 11-subthreshold insomnia); mood was stable (PHQ=5-mild depression). Previous studies have suggested that IRT increases patients’ sense of mastery or perceived self-efficacy over nightmares (Rousseau et al., 2018). Additionally, higher verbal memory in persons with trauma-related nightmares has been shown to improve nightmare frequency and severity in IRT (Scott et al., 2017). In this case study, self-efficacy may have been activated by the highly detailed and media-enhanced imagery the patient created. Further empirical research on the mechanisms for enhancing IRT is warranted.