Efficacy of a Therapist-Assisted Self-Help Internet-Based Intervention Targeting PTSD, Depression, and Insomnia Symptoms After a Disaster: A Randomized Controlled Trial.

This study aimed at evaluating the efficacy of an online CBT intervention with limited therapist contact targeting a range of posttraumatic symptoms among evacuees from the 2016 Fort McMurray wildfires. One hundred and thirty-six residents of Fort McMurray who reported either moderate PTSD symptoms (PCL-5 ≥ 23) or mild PTSD symptoms (PCL-5 ≥ 10) with moderate depression (PHQ-9 ≥ 10) or subthreshold insomnia symptoms (ISI ≥ 8) were randomized either to a treatment (n = 69) or a waitlist condition (n = 67). Participants were on average 45 years old, and mostly identified as White (82%) and as women (76%). Primary outcomes were PTSD, depression, and insomnia symptoms. Secondary outcomes were anxiety symptoms and disability. Significant Assessment Time × Treatment Condition interactions were observed on all outcomes, indicating that access to the treatment led to a decrease in posttraumatic stress (F[1,117.04] = 12.128, p = .001; d = .519, 95% CI = .142-.895), depression (F[1,118.29] = 9.978, p = .002; d = .519, 95% CI = .141-.898) insomnia (F[1,117.60] = 4.574, p = .035; d = .512, 95% CI = .132-.892), and anxiety (F[1,119.64] = 5.465, p = .021; d = .421, 95% CI = .044-.797) symptom severity and disability (F[1,111.55] = 7.015, p = .009; d = .582, 95% CI = .200-.963). Larger effect sizes (d = 0.823-1.075) were observed in participants who completed at least half of the treatment. The RESILIENT online treatment platform was successful to provide access to specialized evidence-based mental health care after a disaster.

The effect of an Internet-based cognitive behavioral therapy intervention on social support in disaster evacuees.

INTRODUCTION: Both exposure to a natural disaster and psychological symptoms may lead to decreases in social support. Few studies have examined ways to improve social support among victims of natural disasters. AIMS: The objective of the study was to assess emotional and tangible support following a 12-session Internet-based cognitive behavioral therapy (ICBT) targeting posttraumatic stress (PTS), insomnia, and depression symptoms and to examine the association between posttreatment symptoms and emotional and tangible support. MATERIALS AND METHODS: One hundred and seventy-eight wildfire evacuees with significant PTS, depression and/or insomnia symptoms were given access to the ICBT. They completed questionnaires at pre- and posttreatment to measure social support and symptom severity. RESULTS: Results show that completion of the treatment led to an improvement in emotional support. Lower posttreatment PTS and insomnia symptoms were associated with higher posttreatment emotional support. CONCLUSION: ICBT may contribute to enhance emotional support through symptom improvement and probably more so when social support is address directly in treatment.

The moderating and mediating role of telepresence and cognitive change in cognitive behaviour therapy delivered via videoconference.

In this study, we combined the results of two controlled trials and examined the relationships between working alliance, telepresence, cognitive change and treatment outcome. Sixty-five participants with a primary diagnosis of generalized anxiety disorder (GAD) or panic disorder with agoraphobia (PDA) received cognitive behaviour therapy delivered via videoconference. Participants completed measures of working alliance and telepresence after three psychotherapy sessions. They also completed measures of treatment outcome and dysfunctional beliefs (cognitive change) specific to PDA and GAD at pretreatment and posttreatment. Results revealed that telepresence at the fifth session moderated the relationship between the working alliance at the first and fifth sessions. As telepresence increased, its impact on the working alliance diminished. Cognitive change mediated the relationship between the working alliance at the fifth session and treatment outcome.

[Influence of Comorbidity in Cognitive-Behavioral Treatment of Anxiety and Mood Disorders]. / Influence de la comorbidité dans le traitement cognitif-comportemental des troubles anxieux et de l'humeur.

Objectives Anxiety and depression are the most prevalent disorders observed in health care services and are frequently comorbid with other disorders. Although Cognitive-Behavioral Therapy (CBT) has widely been shown efficacious to treat anxiety and mood disorders, studies that have focused on its effectiveness in the presence of comorbidity have been few and show conflicting results. Thus, the implications of the presence of comorbid disorders for treatment are still unknown. In an attempt to answer these questions, this study explores the impact of comorbidity on CBT for anxiety and mood disorders in a university-based clinic. Methods A total of 293 clients consulting for anxiety and/or mood disorders at the Service de Consultation de l'École de Psychologie de l'Université Laval (SCEP) between 2007 and 2018 took part in the study. Clients were excluded if they presented uncontrolled psychotic, manic or substance abuse symptoms as their principal complaint. Clients without comorbid disorders where compared to clients who had comorbid disorders on different measures before and after receiving therapy to examine if comorbidity had an impact on CBT effectiveness to treat the principal disorder. The impact of treatment on comorbid disorders was also investigated. Effectiveness was assessed on several measures before and after treatment including the severity of diagnoses (measured with a structured interview), anxiety and mood symptoms as well as quality of life. Repeated measures ANOVAs and t-tests were used. Results Before initiating therapy, clients with comorbid disorders had significantly more severe symptoms than clients without comorbid disorders. However, following therapy, both groups had significantly less severe principal disorders and reached a clinically significant change in equivalent proportions. Furthermore, the number and severity of comorbid disorders significantly decreased following therapy. Conclusion These findings suggest that although the presence of comorbid disorders leads to more severe symptoms, it does not affect the effectiveness of CBT for the principal disorder. Furthermore, comorbid disorders improved even though they were not specifically targeted by treatment. In concordance with the literature, it is thus suggested to keep focusing treatment on the principal disorder, whether comorbid disorders are present or not.

Gender Differences in Usage and Subjective Appreciation of an Online Cognitive Behavioral Therapy for Wildfire Evacuees: Descriptive Study.

BACKGROUND: Based on the most common psychological difficulties of the evacuees from the 2016 Fort McMurray wildfires in Alberta, Canada, a therapist-guided cognitive behavioral self-treatment was developed. This study aimed to explore how gender influences the usage and subjective appreciation of the RESILIENT online treatment. METHODS: Our study included 81 English-speaking evacuees with significant posttraumatic symptoms, or with some posttraumatic symptoms accompanied by at least mild depression symptoms or subclinical insomnia, and who logged into the platform at least once. Various usage and subjective appreciation variables were analyzed, including number of completed sessions, number of logins, number of words per session, perceived efforts, perception of usefulness and intention to continue using the different strategies. RESULTS: No difference was detected in most objective usage indicators. The number of words written in sessions 7 and 10 was significantly greater for women than for men. Regarding subjective appreciation, men had a greater perception of having put strong efforts in the cognitive restructuring strategy, while women reported in a greater proportion that they wanted to continue using physical exercise as a behavioral activation strategy. CONCLUSIONS: Our study offers a first look into how women and men use online treatments, and what their preferences are.

A Multisite Non-Inferiority Randomized Controlled Trial of the Efficacy of Cognitive-Behavior Therapy for Generalized Anxiety Disorder Delivered by Videoconference.

Delivering psychotherapy by videoconference has been studied in a number of clinical trials, but no large controlled trial has involved generalized anxiety disorder (GAD). This multicenter randomized controlled non-inferiority trial was conducted to test if cognitive-behavior psychotherapy delivered by videoconference (VCP) is as effective as cognitive-behavior psychotherapy delivered face-to-face, using a strict margin of tolerance for non-inferiority. A total of 148 adults received a 15-session weekly manualized program. The treatment was based on the intolerance of uncertainty model of GAD. The impact of treatment was assessed using primary (GAD severity), secondary (worry, anxiety, and intolerance of uncertainty) and tertiary (general functioning) variables measured before and after treatment and at 6-month and 12-month follow-ups. Results showed that: (a) the treatment was effective; (b) VCP for GAD was statistically non-inferior to face-to-face psychotherapy on primary, secondary and tertiary measures at all assessment points; (c) change in intolerance of uncertainty significantly predicted change in the primary outcome measure over and above important clinical factors common to all psychotherapies (motivation, working alliance, perceived therapist competence, and client satisfaction). These findings support the use of VCP as a promising treatment option for adults with GAD. Clinical trial registry: ISRCTN#12662027.

Trainee Therapists' Perceptions of a Blended Intervention to Promote Resilience after a Natural Disaster: A Qualitative Case Study.

BACKGROUND: Natural disasters happen in an increased frequency, and telemental health interventions could offer easily accessible help to reduce mental health symptoms experienced by survivors. However, there are very few programs offered to natural disaster survivors, and no research exists on therapists' experiences with providing blended interventions for natural disaster survivors. AIMS: Our qualitative case study aims to describe psychologists' experiences with an online, therapist-assisted blended intervention for survivors of the Fort McMurray wildfires in Alberta, Canada. METHOD: The RESILIENT intervention was developed in the frames of a randomized controlled trial to promote resilience after the Fort McMurray wildfires by providing survivors free access to a 12-module, therapist-assisted intervention, aiming to improve post-traumatic stress, insomnia, and depression symptoms. A focus group design was used to collect data from the therapists, and emerging common themes were identified by thematic analysis. RESULTS: Therapists felt they could build strong alliances and communicate emotions and empathy effectively, although the lack of nonverbal cues posed some challenges. The intervention, according to participating therapists, was less suitable for participants in high-stress situations and in case of discrepancy between client expectations and the intervention content. Moreover, the therapists perceived specific interventions as easy-to-use or as more challenging based on their complexity and on the therapist support needed for executing them. Client engagement in the program emerged as an underlying theme that had fundamental impact on alliance, communication, and ultimately, treatment efficiency. Therapist training and supervision was perceived as crucial for the success of the program delivery. CONCLUSIONS: Our findings provided several implications for the optimalization of blended interventions for natural disaster survivors from our therapists' perspective.

Anxiety symptoms and disorders in the first year after sustaining mild traumatic brain injury.

PURPOSE/OBJECTIVE: The goals of the present study were (a) to document the prevalence of anxiety-related disorders and anxiety symptoms at 4, 8, and 12 months postinjury in individuals with mild traumatic brain injury (mTBI) while considering preinjury history of anxiety disorders and (b) to verify whether the presence of anxiety in the first months after mTBI was associated with more symptoms present 1 year after the injury. Research Method/Design: One hundred and twenty participants hospitalized after an accident and having sustained mTBI were assessed at 4, 8, and 12 months postaccident with the Mini-International Neuropsychiatric Interview, the Hospital Anxiety and Depression Scale, and questionnaires assessing fatigue, irritability, perceived stress, cognitive difficulties, depression, insomnia, and pain. RESULTS: At 4 months, 23.8% of participants presented with at least one anxiety-related disorder compared with 15.2% at 8 months and 11.2% at 12 months. Overall, 32.5% presented with at least one anxiety disorder over the first 12 months post-mTBI. Participants with a history of anxiety (20.5%) were significantly more anxious after their accident. Individuals who were anxious 4 months after the accident presented with more symptoms in different areas 12 months postinjury compared with nonanxious individuals. CONCLUSIONS/IMPLICATIONS: The present results highlight that anxiety should be evaluated and managed carefully as it appears to be a key factor in the persistence of other mTBI-related symptoms. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Experience and Perceived Consequences of the 2016 Fort McMurray Fires and Evacuation.

Few studies have examined the scope of the subjective experience during and after a natural disaster. This qualitative study explored the perceptions of persons affected by the wildfires and evacuation of Fort McMurray in 2016. The objectives were to document (1) the experience of the evacuation, and (2) the biopsychosocial consequences of the wildfires as perceived by evacuees from Fort McMurray 3 months and 3 years after evacuation. This study included two data collections, one from 393 evacuees 3 months after evacuation using an online questionnaire, and the other from 31 participants (among those who participated in the 3-month evaluation) interviewed by telephone 3 years after evacuation. Eight themes describing the evacuation experience emerged from the qualitative analysis: the preparation for evacuation, the perceived traumatic nature of the evacuation, problems encountered while on the move, assistance received and provided, vulnerability conditions, presence of physical discomfort, relocation and no problem/no response. Seven categories of negative consequences emerged: material and financial loss, emotional/mental health disorders, cognitive impairments, behavioral changes, spiritual/existential reflections, social alterations, and physical conditions. Four categories of positive consequences emerged: posttraumatic growth, resilience/absence of consequences, altruism and community cohesion. This study showed a wide range of perceived consequences of fires and evacuations by Fort McMurray residents. The results highlight the importance of tailoring responses to the needs of evacuees and providing assistance to victims over a long period of time.

[Usage Data of an Online Multidimensional Treatment to Promote Resilience After a Disaster]. / Données d'utilisation d'un autotraitement guidé en ligne pour promouvoir la résilience après une catastrophe naturelle.

Objectives Despite the existence of several online treatments for people with posttraumatic stress disorder (PTSD), few studies have examined usage data for such interventions. Given the potential of the online modality to alleviate barriers limiting access to psychological help, it is important to document users' interactions with these tools in relation to the improvement of targeted symptoms. The objective of this study is to document usage data of the online treatment platform RESILIENT by people evacuated from the Fort McMurray, Alberta (Canada) fires, and to examine their association with the effectiveness of treatment on symptoms of posttraumatic stress disorder (PTSD), insomnia and depression, and adherence to treatment, as measured by the number of modules accessed by participants. Methods Ninety-seven people evacuated from the Fort McMurray fires with symptoms of PTSD, insomnia and depression were included in this study. Participants were invited to use the RESILIENT platform, an online therapist-assisted self-help treatment program that targets PTSD symptoms, sleep and mood, and includes 12 modules offering evidence-based cognitive-behavioural therapy (CBT) strategies. Both objective (e.g., number of modules accessed) and subjective (e.g., level of effort invested) usage data were collected. Results In order to predict the reduction in PTSD, depression and insomnia symptoms, as well as the number of modules accessed by participants, sequential regression models were conducted, with statistical control for pretreatment symptoms, age and gender. The final models revealed that a reduction in PTSD, depression and insomnia symptoms was significantly predicted by the number of modules accessed (ß = -.41; -.53; -.49 respectively, all p <.001) as well as the mean self-reported level of effort at module 7 (midway) (ß = -.43; p <.001; ß = -.38; p = .005 and ß = -.36; p = .007 respectively). The number of modules accessed, on the other hand, was significantly predicted by the number of words in the 4th module (ß = .34; p <.001) and 7th module (ß = .44; p <.001) and the number of sleep diary entries (ß = .28; p <.001). Conclusion These results confirmed that increased interaction with the platform positively influences treatment effectiveness and that increased use at the beginning of treatment appears to be a good predictor of treatment completion. This study confirms the importance of sustaining participants' commitment to online treatment in order to optimize its effectiveness.

Psychological Symptoms Among Evacuees From the 2016 Fort McMurray Wildfires: A Population-Based Survey One Year Later.

Background: The 2016 wildfires in Fort McMurray (Alberta, Canada) led to a massive displacement of 88,000 people and destroyed 2,400 homes. Although no direct human fatality resulted, many individuals feared for their lives or those of their loved ones. Objectives: (1) To estimate the prevalence of post-traumatic stress, major depressive, insomnia, generalized anxiety, and substance use disorders in the adult population of Fort McMurray 1 year after the evacuation; (2) To identify pre-, peri-, and post-disaster correlates of mental health disorders. Methods: A phone survey using random digit sampling was used to survey evacuees. A total of 1,510 evacuees (response rate = 40.2%, 55.5% women, mean age = 44.11, SD = 12.69) were interviewed between May 9th and July 28th, 2017. Five validated scales were administered: the PTSD Symptoms Checklist (PCL-5), the Insomnia Severity Index (ISI), the depression and anxiety subscales of the Patient Health Questionnaire (PHQ-9, GAD-7), and the CAGE Substance Abuse Screening Tool. Results: One year after the wildfires, 38% had a probable diagnosis of either post-traumatic stress, major depressive, insomnia, generalized anxiety, or substance use disorder, or a combination of these. Insomnia disorder was the most common, with an estimated prevalence of 28.5%. Post-traumatic stress, major depressive and generalized anxiety disorders were almost equally prevalent, with ~15% each. The estimated prevalence of substance use disorder was 7.9%. For all five mental health disorders, having a mental health condition prior to the fires was a significant risk factor, as well as having experienced financial stress or strain due to the economic decline already present in Fort McMurray. Five post-disaster consequences were significant predictors of four of the five disorders: decrease in work, decrease in social life, poorer current health status, increase in drug and alcohol use, and higher level of stress experienced since the fires. Conclusion: One year after the fires, more than one third of the evacuees had clinically significant psychological symptoms, including those of insomnia, post-traumatic stress, depression, anxiety, and substance use. This study helped identify individuals more at risk for mental health issues after a natural disaster and could guide post-disaster psychosocial support strategies.

The Role of Intolerance of Uncertainty and Working Alliance in the Outcome of Cognitive Behavioral Therapy for Generalized Anxiety Disorder Delivered by Videoconference: Mediation Analysis.

BACKGROUND: Previous meta-analyses have shown a significant relationship between working alliance and treatment outcome in general. Some studies have examined the relationship between working alliance and treatment outcome during telepsychotherapy, but to the best of our knowledge, no study has examined the mediating role of individual components of the working alliance. OBJECTIVE: As part of a clinical trial of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) delivered by videoconference (VC), the aim of this study is to examine the mediating role of intolerance of uncertainty on the relationship between the components of the working alliance and treatment outcome. METHODS: A sample of 46 adults with primary GAD received 15 sessions of CBT for GAD delivered over VC. Participants completed the measure of working alliance immediately after the fifth therapy session. The degree of change in intolerance of uncertainty (a key psychological process) was assessed from pre- to posttreatment. Treatment outcome was assessed via changes in GAD symptoms from pretreatment to the 6-month follow-up. RESULTS: The results revealed that the therapeutic bond did not predict treatment outcome (r=-0.23; P=.12). However, agreement on therapeutic goals and tasks did predict treatment outcome (r=-0.42; P=.004 and r=-0.37; P=.01, respectively). In addition, the relationship between consensus on therapeutic tasks and treatment outcome was completely mediated by changes in intolerance of uncertainty (unstandardized ß=-0.03; r2=0.12), whereas consensus relative to treatment goals had a direct impact on treatment outcome. CONCLUSIONS: These results provide a better understanding of the differential role of the components of the working alliance in telepsychotherapy as a facilitative factor for changes in key cognitive processes, leading to therapeutic change. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 12662027; http://www.isrctn.com/ISRCTN12662027.

A Portrait of Mental Health Services Utilization and Perceived Barriers to Care in Men and Women Evacuated During the 2016 Fort McMurray Wildfires.

This study examines the influence of gender on mental health services utilization and on perceived barriers to treatment one year after the 2016 Fort McMurray wildfires. Data was collected through a phone survey from May to July 2017 (N = 1510). Participants were English-speaking evacuees aged 18 and older. Mental health services utilization and barriers to mental health care were assessed with the Perceived Need for Care questionnaire. Probable diagnoses of posttraumatic stress disorder, depression and insomnia were assessed with validated self-report questionnaires. Multiple logistic regressions confirmed that gender was a significant predictor of services utilization, after controlling for associated sociodemographic variables and presence of probable diagnoses. Women were respectively 1.50, 1.55 and 1.86 times more likely than men to receive information, medication and psychological help. Self-reliance was the most frequently reported reason for not receiving help, and motivational barriers, such as pessimism and stigma, were reported in a higher proportion than structural barriers, including nonresponse and finance. No significant gender differences were found in the types of perceived barriers to services. Among the Fort McMurray fire evacuees, mental health services utilization was similar to other studies on natural disaster victims, and higher in women than in men. Efforts to increase services utilization in natural disaster victims should focus on motivational barriers and offering treatments fostering people's autonomy, such as online treatments.

A Systematic Review and Meta-analysis on PTSD Following TBI Among Military/Veteran and Civilian Populations.

OBJECTIVES: To determine whether persons with traumatic brain injury (TBI) are at greater risk of developing posttraumatic stress disorder (PTSD) than other trauma-exposed populations without TBI, and whether this risk is even greater in military/veteran settings than in civilian settings. DESIGN: A systematic review and meta-analysis was conducted in 7 databases. Reference lists from the 33 identified studies and other relevant reviews were also searched. RESULTS: The pooled PTSD proportion reached 27% (95% confidence interval = 21.8-33.1) in groups with TBI, which was 2.68 times greater than the observed 11% (95% confidence interval = 8.0-15.0) in groups without TBI. PTSD after TBI was more frequently observed in military samples than in civilians (37% vs 16%). Military and civilian samples were respectively 4.18 and 1.26 times more inclined to have a diagnosis of PTSD after TBI than when there was no TBI. The proportion of PTSD after TBI was concurrently attributable to the methods of the included studies (objectives focused on PTSD diagnosis, type of comparison group) and to characteristics specific to the military setting (country, sex, blast injuries). CONCLUSIONS: TBI diagnosis and military setting represent greater risks for PTSD. The dual diagnosis of TBI and PTSD requires interdisciplinary collaboration, as physical and psychological traumas are closely intertwined.

Post-Traumatic Stress among Evacuees from the 2016 Fort McMurray Wildfires: Exploration of Psychological and Sleep Symptoms Three Months after the Evacuation.

This study documents post-traumatic stress symptoms after the May 2016 wildfires in Fort McMurray (Alberta, Canada). A sample of 379 evacuees completed an online questionnaire from July to September 2016, and a subsample of 55 completed a psychiatric/psychological diagnostic interview. According to a self-report questionnaire, 62.5% of respondents had a provisional post-traumatic stress disorder (PTSD). The interview confirmed that 29.1% met criteria for PTSD, 25.5% for depression, and 43.6% for insomnia; in most cases, insomnia was definitely or probably related to the fires. Traumatic exposure may elicit or exacerbate sleep problems, which are closely associated with PTSD after a disaster.

Sleep disturbances and nightmares in victims of sexual abuse with post-traumatic stress disorder: an analysis of abuse-related characteristics.

Background: Sexual abuse victims often experience symptoms of post-traumatic stress disorder (PTSD), including sleep disturbances. Objective: To investigate whether or not characteristics of sexual abuse are associated with sleep disturbance, and to explore whether correlates of sleep disturbance are distinguishable from those of PTSD symptom severity. Method: Forty-four adult sexual abuse victims seeking treatment for PTSD and sleep disturbances completed validated self-report questionnaires assessing sleep, nightmares, and PTSD symptoms. Results: Age at time of sexual abuse contributed to the severity of distress associated with nightmares, whereas the number of perpetrators contributed to the frequency of nightmares. Sleep disturbances had different correlates compared to those of overall PTSD symptoms. Conclusions: The present study highlighted that age at time of abuse and number of offenders may account for variability in sleep disturbances. Exploration of characteristics of sexual abuse could help clinicians to quickly identify who could benefit the most from targeting nightmares and other sleep disturbances in treatment.

Antecedentes: Las víctimas de abuso sexual a menudo experimentan síntomas de trastorno de estrés postraumático (TEPT), incluidos los trastornos del sueño.Objetivo: Investigar si las características del abuso sexual están o no asociadas con trastornos del sueño y explorar si los correlatos de los trastornos del sueño se distinguen de los de la gravedad de los síntomas del TEPT.Método: Cuarenta y cuatro adultos víctimas de abuso sexual que buscan tratamiento para el TEPT y trastornos del sueño completaron cuestionarios de autoinforme validados que evalúan el sueño, las pesadillas y los síntomas del TEPT.Resultados: La edad en el momento del abuso sexual contribuyó a la severidad de la angustia asociada con las pesadillas, mientras que el número de perpetradores contribuyó a la frecuencia de las pesadillas. Las alteraciones del sueño tenían correlaciones diferentes en comparación con las de los síntomas generales de TEPT.Conclusiones: El presente estudio destacó que la edad en el momento del abuso y la cantidad de perpetradores pueden explicar la variabilidad en los trastornos del sueño. La exploración de las características del abuso sexual podría ayudar a los médicos a identificar rápidamente quién podría beneficiarse al máximo al focalizarse en pesadillas y otros trastornos del sueño durante el tratamiento.

Self-efficacy as a Mechanism of Action of Imagery Rehearsal Therapy's Effectiveness: An Exploratory Mediation Analysis.

Imagery rehearsal therapy (IRT) is an empirically validated therapy targeting recurring nightmares, for which the mechanisms of action remain poorly understood. The objective of this study was to investigate how an exploratory measure of self-efficacy could mediate IRT's effectiveness. Thirty-five victims of sexual assault with recurring nightmares were randomly assigned to either IRT or a control condition. Participants completed questionnaires about self-efficacy and nocturnal symptoms at pre- and posttreatment. Regression analyses showed that IRT predicted greater self-efficacy about dreams (ß = .578) and that self-efficacy about dreams predicted improvement in insomnia (ß = -.378). IRT also predicted greater self-efficacy about nightmares (ß = .366), which in turn predicts sleep quality (ß = -.412). However, self-efficacy was not a significant mediator of IRT's effectiveness on insomnia and sleep quality. Although IRT did increase patients' self-efficacy over dreams and nightmares, self-efficacy may not be a primary mechanism of action explaining IRT's effectiveness.

Efficacy of Imagery Rehearsal Therapy and Cognitive Behavioral Therapy in Sexual Assault Victims With Posttraumatic Stress Disorder: A Randomized Controlled Trial.

Sleep disturbances are common among sexual assault victims with posttraumatic stress disorder (PTSD), but cognitive behavioral therapy (CBT) for PTSD does not directly address sleep-related symptoms. Trauma-related sleep disturbances are associated with more impairment and contribute to the maintenance of PTSD. In this study, we evaluated the efficacy of a combination of CBT and nightmare therapy (imagery rehearsal therapy; IRT) compared to CBT alone for the treatment of PTSD. We recruited 42 adult victims of sexual assault who were suffering from PTSD and randomly assigned them to either the experimental (IRT + CBT) or control condition (waiting period followed by CBT). After CBT, both groups demonstrated significant decreases in nighttime symptoms (except nightmare frequency) and PTSD symptoms and showed improvements in functional impairment and mental health, ds = 0.13-0.83, ps = .005-.008. Outcomes between the two groups did not differ significantly after CBT; however, we observed medium to medium-large differences between the control group and experimental group in terms of nighttime symptoms, ds = 0.45-0.63. Although results did not clearly establish the superiority of IRT + CBT over CBT alone, they demonstrated that IRT yielded greater improvement in nighttime symptoms than the waiting period, ds = 0.72-1.13, ps = .006-.047 for all interaction effects. Findings suggest that targeting nightmares at the beginning of treatment for PTSD may yield rapid improvement in nighttime symptoms. This strategy could be useful for patients with time or resource constraints or those for whom nightmares are the primary complaint.

The mechanisms of action underlying the efficacy of psychological nightmare treatments: A systematic review and thematic analysis of discussed hypotheses.

Studies of psychotherapeutic treatments for nightmares have yielded support for their effectiveness. However, no consensus exists to explain how they work. This study combines a systematic review with a qualitative thematic analysis to identify and categorize the existing proposed mechanisms of action (MAs) of nightmare treatments. The systematic review allowed for a great number of scholarly publications on supported psychological treatments for nightmares to be identified. Characteristics of the study and citations regarding potential MAs were extracted using a standardized coding grid. Then, thematic analysis allowed citations to be grouped under six different categories of possible MAs according to their similarities and differences. Results reveal that an increased sense of mastery was the most often cited hypothesis to explain the efficacy of nightmare psychotherapies. Other mechanisms included emotional processing leading to modification of the fear structure, modification of beliefs, restoration of sleep functions, decreased arousal, and prevention of avoidance. An illustration of the different variables involved in the treatment of nightmares is proposed. Different avenues for operationalization of these MAs are put forth to enable future research on nightmare treatments to measure and link them to efficacy measures, and test the implications of the illustration.