Nightmare Rescripting: Using Imagery Techniques to Treat Sleep Disturbances in Post-traumatic Stress Disorder

Marzia Albanese, Marianna Liotti, Lucia Cornacchia, Francesco Mancini (2022): Nightmare Rescripting: Using Imagery Techniques to Treat Sleep Disturbances in Post-traumatic Stress Disorder. In: Frontiers in Psychiatry, 2022.


Besides affecting 8% of the general population, nightmares are one of the most frequent symptoms of traumatized individuals. This can be a significant factor in the treatment of post-traumatic disorders; indeed, several studies demonstrated its strong predictive and prognostic value. Sleep disorders, nightmares in particular, could be very distressing for individuals and need targeted interventions, especially if they are associated with a PTSD diagnosis. To date, the best technique for the treatment of traumatic sleep disturbances seems to be Imagery Rehearsal Therapy (IRT), an empirically supported method. Through a review of the literature on this matter, this article aims to outline the incidence and consequences of nightmares in PTSD, illustrate how IRT could prove useful in their treatment, and investigate its clinical applications.

Post-traumatic stress disorder (PTSD) is a mental health condition, which in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5; (1)] has been included in a new category, “Trauma and Stressor Related Disorders.” PTSD is characterized by the appearance of a wide array of symptoms after experiencing “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence” [(1), p. 271], in the following ways: direct exposure to the event; witnessing the event; learning that a close one was exposed to a traumatic event; indirect exposure to details of the trauma.

PTSD diagnosis was added–not without many controversies–only in the third edition of the DSM [DSM-III; (2)], after noticing the development of post-traumatic symptoms among many veteran soldiers. However, it is possible to identify some descriptions ascribable to this disorder already at the beginning of the twentieth century, when many authors spoke of “war neurosis,” “soldier's heart,” and “shell shock” to describe the physio-psychological consequences of being exposed to war situations [for a historical overview, see (3)]. Shortly after the diagnosis of PTSD was introduced in the DSM, clinicians began to notice that there were other individuals–victims of sexual or physical abuse, for example–whose symptoms largely corresponded with those observed in soldiers. Today we know that the traumatic events that can give rise to PTSD are numerous and of various kinds. They produce lasting effects, which the DSM-5 describes as follows, dividing them into four clusters:

1) Re-experience of the traumatic event (intrusion symptoms) through distressing memories, dreams and nightmares, flashbacks, and dissociative reactions.

2) Avoidance of stimuli associated with the traumatic event.

3) Negative alterations in cognition and mood (e.g., amnesia, negative beliefs and expectations, distorted cognitions, feelings of detachment).

4) Marked alterations in arousal and reactivity (e.g., irritability, self-destructive behaviors, hypervigilance, difficulties in concentrating, sleep disturbances).

According to the DSM-5, in the United States PTSD affects ~5% of men and 10% of women (1). In Italy, epidemiological studies show that about 56.1% of the general population is exposed to at least one traumatic event (with an average of 4 traumatic events experienced during the lifespan); the risk of experiencing PTSD following exposure to a traumatic event(s) is assessed to be between 0.8 and 12.2% (4). These data highlight the significance of a better understanding of the complex symptoms that are often associated with PTSD to develop targeted and effective intervention techniques.