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Volume 15 No. 05
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Accepted Papers

Scientific Investigations

Randomized Controlled Trial of Imagery Rehearsal for Posttraumatic Nightmares in Combat Veterans

Gerlinde C. Harb, PhD1; Joan M. Cook, PhD2; Andrea J. Phelps, PhD3; Philip R. Gehrman, PhD1,4; David Forbes, PhD3; Russell Localio, PhD4; Ilan Harpaz-Rotem, PhD2; Ruben C. Gur, PhD4; Richard J. Ross, MD, PhD1,4
1Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; 2Yale University and National Center for PTSD, New Haven, Connecticut; 3Phoenix Australia Centre for Posttraumatic Mental Health, Melbourne, Australia; 4University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania

Study Objectives:

To examine the efficacy of imagery rehearsal (IR) combined with cognitive behavioral therapy for insomnia (CBT-I) compared to CBT-I alone for treating recurrent nightmares in military veterans with posttraumatic stress disorder (PTSD).


In this randomized controlled study, 108 male and female United States veterans of the Iraq and Afghanistan conflicts with current, severe PTSD and recurrent, deployment-related nightmares were randomized to six sessions of IR + CBT-I (n = 55) or CBT-I (n = 53). Primary outcomes were measured with the Nightmare Frequency Questionnaire (NFQ) and Nightmare Distress Questionnaire (NDQ).


Improvement with treatment was significant (29% with reduction in nightmare frequency and 22% with remission). Overall, IR + CBT-I was not superior to CBT-I (NFQ: −0.12; 95% confidence interval = −0.87 to 0.63; likelihood ratio chi square = 4.7(3), P = .2); NDQ: 1.5, 95% confidence interval = −1.4 to 4.4; likelihood ratio chi square = 7.3, P = .06).


Combining IR with CBT-I conferred no advantage overall. Further research is essential to examine the possibly greater benefit of adding IR to CBT-I for some subgroups of veterans with PTSD.

Clinical Trial Registration:

Registry:; Title: Cognitive Behavioral Therapy (CBT) for Nightmares in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans; Identifier: NCT00691626; URL:


Harb GC, Cook JM, Phelps AJ, Gehrman PR, Forbes D, Localio R, Harpaz-Rotem I, Gur RC, Ross RJ. Randomized controlled trial of imagery rehearsal for posttraumatic nightmares in combat veterans. J Clin Sleep Med. 2019;15(5):757–767.

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