Imagery Rehearsal Therapy Groups
2. Project period
The project will start 1st of August 2018 and end 1st of August 2025
Ida Poschmann and Jessica Carlsson
4. Supervisors and collaborative partners
Birgitte Vest and Hannah Rathke as data collectors
Sleep disturbances are viewed as a hallmark symptom of PTSD and as many as 70 -87% of people suffering
from PTSD describe sleep disturbances (Germain 2013). Moreover, sleep disturbances might be a risk factor
for poor outcome of PTSD treatment since poor sleep may obstruct PTSD patients’ ability to engage in and
benefit from first-line PTSD treatment. Furthermore, sleep disturbances have been found to be a residual
symptom after various kinds of PTSD treatments (Spoormaker & Montgomery 2008). There is therefore a
great need for research examining how we can include treatment of sleep disturbances and nightmares to
standard treatment of PTSD.
Imagery Rehearsal Therapy (IRT) is one of few therapeutic methods developed specifically to target and
treat patients suffering from nightmares and sleep disturbances and is designed for group treatment
(Krakow & Zadra 2010). Contrary to many first-line PTSD treatment methods IRT is not a trauma focused
treatment method and it minimizes exposure to trauma content. IRT was selected for this study to offer a
treatment method that minimizes exposure and trauma focus, hoping that a greater number of PTSD
patients would be capable and willing to engage in IRT group treatment.
IRT has been tested on diverse PTSD patient groups, such as amongst veterans (Nappi Drummond & Hall
2010) and sexual assault victims (Krakow Hollifield, Schrader, Koss, Tandberg, Lauriello, McBride, Werner,
Cheng, Edmond & Kellner 2000; Krakow, Hollifield, Johnston, Koss, Schrader, Warner, Tandberg, Lauriello,
McBride, Cutchen, Cheng, Rmmons, Germain, Melendrez Sandival, & Prince 2001), showing promising
results in treating posttraumatic nightmares and sleep disturbances. These findings sparked an interest in
investigating if this method could be used for the two selected groups of PTSD patients: Migrant patients
being treated at CTP and non-migrant patients being treated at DP. To the knowledge of the author no
research exists comparing two groups of patients with PTSD receiving group IRT.
The overall aim of the current study is to 1) determine if IRT group treatment is an acceptable treatment
method for the two groups of PTSD patients. The second aim is to 2) examine the patients’ experiences
through IRT by measuring changes to different parameters of nightmare frequency, nightmare distress,
nightmare themes, dream activity and homework practice reported by the patients on a sleep log and
group parameters rated by the IRT therapists. The third aim is to 3) monitor indicators of effect of IRT by examine if changes can be detected in; patients’ sleep quality, PTSD symptoms, level of functioning and
overall life quality through standardized ratings before, in the middle of and after IRT. The fourth and last
aim of the study is to 4) compare the data of the two patient groups.
7.1 Number of participants (N)
IRT treatment groups with 4 to 8 patients pr. group is established in each of the two clinics. At CTP there
will be one group for women and one for men and at DP one IRT group of both women and men. Hence the
number of patients in the study may vary from 12 to 24 depending on the size of the groups.
Migrant patients being treated at CTP and non-migrant patients being treated at DP.
7.3 Description of data and data collection
This pilot study sets out to determine if IRT in a group setting is an acceptable treatment method for
patients suffering from PTSD with related nightmares and sleep disturbances as the first aim. This is done
by monitoring indicators of acceptability: attendance, homework practice monitored individually as well as
the group session ratings described above. Additionally, acceptability of IRT will also be discussed during
The second aim to examine the patients’ experiences through IRT including changes on parameters of
nightmare frequency, nightmare distress, nightmare themes, dream activity and homework practice which
is measured by the sleep log and noted on the CRF during every session as well as the group parameters
rated by the IRT therapists. The third aim is answered through standardized ratings to examine if changes
can be detected in; patients’ sleep quality, PTSD symptoms, level of functioning and overall life quality
before, mid and after IRT treatment.
Finally, the fourth aim is to carry out a number of comparisons between the two patient groups’ in relation
to acceptability (attendance, homework practice as well as the group session ratings), the patients
experiences with the IRT group (including changes on parameters of nightmare frequency, nightmare
distress, nightmare themes, dream activity measured by the sleep log) and the pre, mid and port IRT
ratings. These comparisons will be qualitative due to the small number of participants.
7.4 Application/acceptance from the Danish Data Protection Agency, the National Committee on Health
The project has received acceptance from the Danish Data Protection Agency, the National Committee on
Health Research Ethics
Only limited and primarily descriptive statistics will be carried out due to the small sample size.
8. Expected results
It is expected that the IRT group format will be acceptable for most patients and that most patients will
experience improvement to nightmare frequency and nightmare distress and changes to nightmare themes
and dream activity. Indications of a positive effect on sleep quality, PTSD symptoms, level of functioning
and overall life quality is expected. It is also expected that the study will find differences between the two
groups of the migrant patients and non-migrant patients in relation to group dynamics.
9. Dissemination of results
It is expected that the project will result in approximately 2 publications. Findings will be published in
international peer-reviewed journals. Furthermore, the results will be presented at relevant conferences.
- Germain, A., & Ph, D. (2013). Sleep Disturbances as the Hallmark of PTSD, American Journal of Psychiatry,
- Spoormaker, V. I., & Montgomery, P. (2008). Disturbed sleep in post-traumatic stress disorder: secondary
symptom or core feature? Sleep Medicine Reviews, 12(3), 169–84.
- Krakow, B., & Zadra, A. (2010). Imagery rehearsal therapy: Principles and practice. Sleep Medicine Clinics,
5(2), 289–298. http://doi.org/10.1016/j.jsmc.2010.01.004. 19 np.
- Nappi, C. M., Drummond, S. P. A., & Hall, J. M. H. (2012). Neuropharmacology Treating nightmares and
insomnia in posttraumatic stress disorder: A review of current evidence. Neuropharmacology, 62(2), 576–
- Krakow, B., Hollifield, M., Schrader, R., Koss, M., Tandberg, D., Lauriello, J., McBride, L., Werner, T. D.,
Cheng, D., Edmond, T. & Kellner, R. (2000). A controlled study of imagery rehearsal for chronic nightmares
in sexual assault survivors with PTSD: A preliminary report. Journal of Traumatic Stress, 13(4), 589–609.
http://doi.org/10.1023/A:1007854015481. 20 np.#
- Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T. D., Tandberg, D., Lauriello, J.,
McBride, L,. Cutchen, L., Cheng, D., Rmmons, S., Germain, A., Melendrez d., Sandival, D. & Prince, H. (2001).
Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress
disorder: a randomized controlled trial. JAMA : the journal of the American Medical Association (Vol. 286).