Integrating Sleep, Nightmare and PTSD Treatments

Study Overview
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Brief Summary
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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.

Official Title
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Integrating Sleep and PTSD Treatment: Examining the Role of Emotion Regulation

Conditions
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Nightmares, PTSD

Intervention / Treatment
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* Behavioral: Exposure, Relaxation, and Rescripting Therapy
* Behavioral: Cognitive Processing Therapy - Cognitive


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 18 Years of Age minimal Experienced a trauma One nightmare per week for past month, minimal meet full criteria for PTSD Exclusion Criteria: 17 years of age or younger acute psychosis bipolar disorder intellectual disability active suicidality untreated substance use disorder within past 6 months

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Cognitive Processing Therapy-Cognitive<br>12 sessions of cognitive processing therapy-Cognitive | Behavioral: Cognitive Processing Therapy - Cognitive<br>* 12 sessions cognitive behavioral treatment targeting posttraumatic stress symptoms.<br>* Other names: CPT;|
| Active Comparator: ERRT + CPT-C<br>5 sessions of Exposure, Relaxation, and Rescripting Therapy, followed by 12 sessions of Cognitive Processing Therapy- Cognitive | Behavioral: Exposure, Relaxation, and Rescripting Therapy<br>* 5 sessions that last approximately one hour addressing nightmares and sleep problems. Participants will log sleep events and associated symptoms<br>* Other names: IRT;Behavioral: Cognitive Processing Therapy - Cognitive<br>* 12 sessions cognitive behavioral treatment targeting posttraumatic stress symptoms.<br>* Other names: CPT;|
| Active Comparator: CPT-C + ERRT<br>12 sessions of Cognitive Processing Therapy - Cognitive, followed by 5 sessions of Exposure, Relaxation, and Rescripting Therapy | Behavioral: Exposure, Relaxation, and Rescripting Therapy<br>* 5 sessions that last approximately one hour addressing nightmares and sleep problems. Participants will log sleep events and associated symptoms<br>* Other names: IRT;Behavioral: Cognitive Processing Therapy - Cognitive<br>* 12 sessions cognitive behavioral treatment targeting posttraumatic stress symptoms.<br>* Other names: CPT;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Nightmare Frequency | A fill-in-the blank question (range = 0-X nightmares) from the Trauma Related Nightmare Survey will be utilized to determine the past week nightmare frequency at baseline, and 3 and 6 months follow-up. Higher values indicate more nightmares. | up to 6-months follow-up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Clinician Administered PTSD Scale | This semi-structured clinical interview assesses severity of each of 30 items measuring Diagnostic and Statistical Manual (DSM-5) criteria for PTSD on a 5-point scale (0 - 4), (possible range: 0-80). A symptom is considered present if the severity is rated 2 or higher. Total scores are comprised of four factors (reexperiencing, avoidance, cognitive/emotional and hyperarousal) | Past Month symptoms measured at baseline, and 3 and 6 month follow-up | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Nightmare, PTSD, Sleep, Emotion Regulation, Exposure Relaxation and Rescripting Therapy, Cognitive Processing Therapy