Integrating Sleep, Nightmare and PTSD Treatments

The purpose of the proposed pilot study is to extend previous findings regarding the efficacy
of a brief treatment for chronic posttrauma nightmares and sleep problems by integrating this
treatment with evidence-based treatment for posttraumatic stress disorder (PTSD). Cognitive
processing therapy (CPT) (Resick & Schnicke, 1996) is a well-established and efficacious
evidence-based psychological treatment for PTSD in both civilian and veteran populations
(Forbes et al., 2012; Monson et al., 2006; Resick et al., 2008; Resick, Nishith, Weaver,
Astin, & Feuer, 2002). The U.S. Department of Veterans Affairs (VA) includes CPT among the
first-line treatments for PTSD (National Center for PTSD, 2012). A modified protocol without
the utilization of written exposure (CPT-C) may be more effective than the original protocol.
However, despite such promising evidence, individuals who experience chronic nightmares and
sleep problems tend to show smaller gains and persistent nightmares following PTSD treatment
(Nappi, Drummond, & Hall, 2012). Given that nightmares are considered the hallmark of PTSD
(Ross, Ball, Sullivan, & Caroff, 1989) and their treatment-resistant nature (Davis & Wright,
2007), specific psychological treatments have been developed to target sleep disturbances and
nightmares.

Exposure, relaxation, and rescripting therapy (ERRT) is a promising psychological
intervention developed to target trauma-related nightmares and sleep disturbances. Though
further evidence is needed, ERRT has exhibited strong support in reducing the frequency and
intensity of nightmares, as well as improving overall sleep quality in both civilian and
veteran samples. In addition, significant decreases in PTSD and depression symptoms have been
reported following treatment (Davis et al., 2011; Davis & Wright, 2007; Long et al., 2011;
Swanson, Favorite, Horin, & Arnedt, 2009). ERRT is currently an evidence-level B suggested
treatment (Cranston, Davis, Rhudy, & Favorite, 2011).

There is a call to research suggesting the importance of treatment studies which focus on
interventions that integrate nightmare and sleep symptom treatment with evidence-based
treatment for PTSD (Nappi et al., 2012). In an effort to respond to this call, we propose to
tailor ERRT for use in conjunction with CPT, and preliminarily test ERRT's additive effect to
CPT in treating PTSD in community outpatients. We hypothesize that ERRT would increase CPT's
treatment efficacy by its specific focus on trauma-related nightmares and sleep disturbances.
Sleep difficulties are known to increase tension, and reduce one's ability to cope adaptively
(Bonn-Miller, Babson, Vujanovic, & Feldner, 2010; Hofstetter, Lysaker, & Mayeda, 2005;
Nishith, Resick, & Mueser, 2001). Thus, with improved sleep an individual may have additional
personal coping resources for which s/he can use to address the broader trauma issues (Nappi
et al., 2012). To test this integration, we will compare ERRT + CPT, CPT + ERRT, and CPT
alone.