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Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine logoLink to Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine
letter
. 2020 Nov 15;16(11):1993. doi: 10.5664/jcsm.8742

Long-term effects of treatment for chronic nightmares: is imagery rehearsal therapy robust in the COVID-19 pandemic?

Caroline Sierro 1, Wendy Leslie 2, Benjamin Putois 1,3,
PMCID: PMC8034210  PMID: 32780012

Citation:

Sierro C, Leslie W, Putois B. Long-term effects of treatment for chronic nightmares: is imagery rehearsal therapy robust in the COVID-19 pandemic? J Clin Sleep Med. 2020;16(11):1993.


Nightmare frequency increases with exposure to stress. In her May 2020 article, “Spontaneous reporting of onset of disturbing dreams and nightmares related to early life traumatic experiences during the COVID-19 pandemic by patients with posttraumatic stress disorder in remission,” Gupta1 found that 80% of patients reported nightmares linked to traumatic memories and not coronavirus disease 2019 (COVID-19) during spontaneous phone calls. Using standardized assessments to rule out bias, we investigated whether COVID-19 increased the prevalence of bad dreams in patients with chronic nightmares in remission.

In January–February 2020, we assessed the long-term effects of Imagery Rehearsal Therapy (IRT).2 Just before the French lockdown (17th March), 29 of 48 patients completed 4-year follow-up questionnaires. To measure the effect of lockdown on nightmares and estimate IRT robustness, 23 of these patients completed these questionnaires2 again at the end of lockdown (May). According to dream methodology recommendations,3 2 patients were excluded having changed their antidepressant dosages and 1 because a traumatic event unrelated to COVID-19 occurred during lockdown. Our observations of 20 patients (3 men; average age, 39.5 years) with chronic nightmares 4 years post-IRT, with Wilcoxon matched-pairs tests, were presented thereafter.

Before IRT, the mean nightmare frequency per month was 28.8 (SD = 20). After IRT, it remained stable: 8.9 (SD = 8.9) post-IRT, 6.25 (SD = 10.6) at the 4-year follow-up. We confirm Gupta’s results1 that the lockdown period increased nightmare frequency: 19.35 (SD = 32) (Nightmare Frequency Questionnaire: t = 22.0, P = .003); 13/20 (65%) reported increased nightmare frequency and 7/20 (35%) reported no lockdown effect. Only two reported more nightmares during lockdown than pre-IRT (without these two non-responders, nightmare frequency during lockdown was 9.5, SD = 10). The lockdown also deteriorated sleep (Pittsburgh Sleep Quality Index: t = 2.46, P < .05). A significant reduction in PTSD symptoms during IRT continued over 4 years (Posttraumatic Stress Disorder Checklist Scale, t = 20.5, P = .008). No lockdown effect was observed for other traumatic symptoms, generalized self-efficacy, or depression/anxiety.

During lockdown, nightmare content was variable: 85% featured worries, 75% conflict, 60% helplessness, 40% assault or failure, 20% illness, 10% lockdown, and 5% COVID-19. This result confirms that nightmares are not “exact replay” dreams representing actual events. Only 30% dreamed about their original trauma. During such crises, increased nightmare frequency could be interpreted not only as reactivation of traumatic memories but also as an increased need for emotional regulation.4

For treatment responders (n = 18), 4 years after IRT, nightmare frequency was 9 times lower than pretreatment, and the COVID-19 pandemic tripled this frequency, which nevertheless remained 3 times lower than pre-IRT. IRT therefore seems robust to the effects of stress (no renewal effect) and time (no spontaneous recovery).5

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. The authors report no conflicts of interest

REFERENCES

  • 1.Gupta MA. Spontaneous reporting of onset of disturbing dreams and nightmares related to early life traumatic experiences during the COVID-19 pandemic by patients with posttraumatic stress disorder in remission. J Clin Sleep Med. 2020;16(8):1419–1420. 10.5664/jcsm.8562 [DOI] [PMC free article] [PubMed] [Google Scholar]
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