1198 2NITEmares: The Relationship Between Nightmares and Integrated CBT-I and Prolonged Exposure Treatments Among Veterans with Insomnia and PTSD
Kira Clare, Riona Yoshida, Kimberly Savin, Abigail Mack, Peter J. Colvonen
Sleep May 1, 2025 DOI: 10.1093/sleep/zsaf090.1198 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Secondary analysis of a randomized controlled trial Peer reviewed |
|---|---|
| Sample size | 94 |
| Population | Veterans with PTSD and insomnia (23.4% female; 52.1% white; mean age 40, SD=12) |
| Interventions | Integrated CBT-I and PE (CBTI-PE) sleep hygiene and PE (hygiene-PE) |
| Duration | Baseline, 5-week, post-treatment, and 3-month follow-up |
| Measures | PTSD Checklist (PCL-5), Insomnia Severity Index (ISI), seven-day sleep diaries |
| Topics | Dreaming PTSD |
| Key findings | Nightmare frequency and maximum distress decreased significantly over both integrated CBT-I plus PE and sleep hygiene plus PE, with no between-group differences; follow-up analyses suggest PE after week 5 had larger effects on nightmares than either sleep intervention. Baseline nightmare variables did not interfere with PTSD or insomnia treatment outcomes, though residual nightmares and distress remained. |
Abstract
Nightmares and insomnia commonly co-occur with Posttraumatic Stress Disorder (PTSD), with 70% to 91% of individuals with PTSD reporting chronic nightmares and insomnia. Evidence suggests that even gold standard treatments for PTSD (such as Prolonged Exposure, PE) and insomnia (CBT-I) individually may not fully resolve nightmares. Our study presents secondary analyses of a randomized controlled trial of integrated CBT-I and PE (CBTI-PE), compared to sleep hygiene and PE (hygiene-PE) on nightmares. We examined a) how nightmare frequency and maximum distress severity changed over the course of treatments (baseline, 5-week, post, and 3-month follow up); and b) if baseline nightmares interfered with the efficacy of treatment. Participants were 94 Veterans with PTSD and insomnia (23.4% female; 52.1% white; age M= 40, SD=12) with mean baseline PTSD Checklist (PCL-5) score of 55.6 (SD = 12.55) and Insomnia Severity Index (ISI) score of 20.53 (SD = 4.73). Participants completed seven-day sleep diaries including number and severity of distress from nightmares (0-10). Nightmare maximum distress was the highest severity rating. Baseline sleep diaries showed participants averaged 0.86 nightmares per night (SD = 0.89) with maximum distress of 5.69 (SD=1.47) out of 10. Neither baseline average number of nightmares nor maximum nightmare distress correlated with ISI (r=.26, r=.13, p=.32). Only maximum distress correlated with PTSD at baseline (r=.41, p<.001). Hierarchical linear modeling showed that the number nightmares (β = -0.11, p =.002) and maximum distress (β =-0.46, p =.02) significantly decreased over both treatments, but there were no differences between groups. Follow-up analyses suggest that PE (after week 5) had larger effects on nightmares than either sleep intervention. No baseline nightmare variables interfered with PTSD or ISI treatment outcomes. CBTI-PE and hygiene-PE showed decreased nightmare frequency and severity; this may be due to the PTSD treatment. However, there were residual nightmares and maximum distress that may require further intervention. Our finding that nightmares do not have an impact on insomnia and PTSD treatment efficacy is consistent with recent literature. The study was supported by Department of Veterans Affairs RRD Grant (1lK2Rx002120-01).
Comparable studies
Other randomized controlled trials on PTSD, most cited first.