Empirical Research

Below you will find citations and abstracts of the empirical and scientific literature related to ERRT. Due to copyright restrictions of the respective journals, only the abstracts and citation information is provided.

Randomized controlled trial to dismantle Exposure, Relaxation, and Rescripting Therapy (ERRT) for trauma-related nightmares. 

Pruiksma, K. E., Cranston, C. C., Rhudy, J. L., Micol, R. L., & Davis, J. L. (2016).

Objective: The aim of this study was to conduct a preliminary dismantling study of exposure, relaxation, and rescripting therapy (ERRT) for nightmares. Method: Participants (N = 70) were randomized to 1 of 2 conditions: ERRT with nightmare exposure and rescripting (full protocol; EX) or ERRT without nightmare exposure and rescripting (NEX). Participants completed follow-ups at 1 week, 3 months, and 6 months posttreatment. Results: Both conditions yielded statistically significant improvements with medium to large effect sizes on primary outcomes related to nightmares (i.e., nights with nightmares, nightmares per week, and nightmare severity). Both conditions also yielded statistically significant improvements on secondary outcomes with medium to large effect sizes on fear of sleep, sleep quality, insomnia severity, daytime sleepiness, posttraumatic stress disorder symptom severity, and depression severity. The conditions did not differ at any time point. Conclusions: Findings indicate that ERRT with and without nightmare exposure and rescripting can significantly alleviate nightmares and related distress. The addition of nightmare exposure and rescription did not contribute incrementally to outcomes in this sample. It is possible that the dose of exposure was not sufficient to result in group differences or that the treatment components included in both conditions (i.e., psychoeducation about trauma, nightmares, and sleep; sleep habit modification; and relaxation training) may adequately treat factors that maintain nightmares for some individuals. Theoretical implications of findings are discussed. The reduction of symptoms of other conditions following this brief intervention provides further evidence for the primary role of nightmares and sleep disturbances posttrauma.

Psychological Trauma: Theory, Research, Practice, and Policy.

Preliminary validation of a brief measure of the frequency and severity of nightmares: The Trauma-Related Nightmare Survey.
Cranston, C. C., Miller, K. M., Davis, J. L., & Rhudy, J. L. (2016).

Nightmares and sleep disturbances are gaining attention as targets of treatment interventions for trauma-exposed populations. Measures in trials evaluating these interventions tend to utilize proprietary measures of nightmare characteristics, creating a challenge in comparing findings across studies. The Trauma-Related Nightmare Survey (TRNS) is a questionnaire that was initially developed for utilization in efficacy studies of Exposure, Relaxation, and Rescripting Therapy (ERRT). Preliminary examinations of the psychometric properties have demonstrated good test-retest reliability and convergent validity. The present brief report provides an updated examination of these properties and offers the first open publication of the measure for general use. Results support previous findings that the TRNS demonstrates good test-retest reliability (r = .73) and moderate to strong convergent validity (r = .44–.78) with other commonly utilized measures of sleep and mood symptoms.

Journal of Trauma & Dissociation, 18, 88-99.

Efficacy of a Brief Treatment for Nightmares and Sleep Disturbances in Veterans
Balliett, N. E., Davis, J. L., & Miller, K. (2015).
Nightmares and sleep disturbances are common complaints among military Veterans (Plumb & Zelman, 2009) and may be difficult to eradicate (Forbes, Phelps, & McHugh, 2001). A treatment protocol (Exposure, Relaxation, and Rescription Therapy [ERRT]) targeting nightmares and sleep disturbances, which has been used effectively in civilian populations, was adapted for the military (ERRT-M). A pilot study evaluated the efficacy of ERRT-M in improving sleep quality and quantity and reducing nightmares, symptoms of posttraumatic stress disorder, and depression in a trauma-exposed, Veteran sample (N 19). At 1 week after treatment, analyses revealed improvements in nightmare frequency and severity, depression, sleep quality, and insomnia severity. Treatment gains were maintained at a 2-month follow-up. Fifty percent of the sample was considered treatment responders (i.e., no nightmares in the previous week). Results of this pilot study suggest that directly targeting sleep and nightmares is successful in alleviating sleep disturbances and related psychopathology in some Veterans.
Psychological Trauma: Theory, Research, Practice, and Policy 7 (6), 507-515.
Taking Control: Examining the Influence of Locus of Control on the Treatment of Nightmares and Sleep Impairment in Veterans
Miller, K. E., Davis, J. L., & Balliett, N. E. (2014).

Trauma exposure has been linked to external locus of control (E-LOC). This feeling of uncontrollability may be maintained after the trauma by recurring posttrauma nightmares. The present study utilized data from a larger trial, with 19 U.S. veterans, examining the efficacy of a modified version of treatment for nightmares, to examine changes in locus of control in relation to improvements in symptomatology following treatment. Following treatment, internal control beliefs about sleep and nightmares significantly increased, while general control beliefs did not change. Preliminary evidence that exposure, relaxation, and rescripting therapy for military personnel (ERRT-M) is associated with increased sense of control over sleep and nightmares was observed.

Military Behavioral Health, 2(4), 337-342.

A case series: cognitive-behavioral treatment (exposure, relaxation, and rescripting therapy) of trauma-related nightmares experienced by children.
Fernandez, S., Cromer, L. D., Borntrager, C., Swopes, R., Hanson, R. F., & Davis, J. L. (2012).

Two case studies are presented to demonstrate that children who experience trauma-related nightmares may benefit from cognitive-behavioral therapy for this sleep problem. The treatment was adapted from the empirically supported adult treatment for chronic trauma-related nightmares: exposure, relaxation, and rescripting therapy (ERRT). Pretreatment and posttreatment nightmare frequency and severity were measured in addition to subjective nightmare-related distress, behavioral problems, sleep quality and quantity, and symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression. Improvement in nightmare and sleep disturbance frequencies were found as well as reductions in parents’ reports of child behavior problems. This study provides preliminary support for the use of ERRT with children.

Clinical Case Studies, 1534650112462623.

Physiological Predictors of Response to Randomized Clinical Trial of Cognitive Behavioral Therapy for Chronic Nightmares
Davis, J.L., Rhudy, J.L., Pruiksma, K.E., Byrd, P., Williams, A.E., McCabe, K.M., & Bartley, E.J. (2012)

Evidence supports the use of cognitive behavioral therapies for nightmares in trauma- exposed individuals. This randomized clinical trial replicated a study of Exposure, Relaxation, & Rescripting Therapy (ERRT) and extended prior research by including broad measures of mental health difficulties, self-reported physical health problems, and quality of life. Additionally, physiological correlates of treatment-related change assessed from a script-driven imagery paradigm were assessed. Forty-seven individuals were randomized to treatment or waitlist control. The treatment group demonstrated improvements relative to the control group at the one- week post treatment assessment. At the six month follow-up assessment, significant improvements were found for frequency and severity of nightmares, posttraumatic stress disorder symptoms, depression, sleep quality and quantity, physical health symptoms, anger, dissociation, and tension reduction behaviors. Participants also reported improved quality of life. Treatment- related decreases in heart rate to nightmare imagery was correlated with improvements in sleep quality and quantity; treatment-related decreases in skin conductance to nightmare imagery was correlated with improvements in nightmare severity, posttraumatic stress disorder symptom severity, sleep quality, and fear of sleep; and treatment-related decreases in corrugator activity to nightmare imagery was correlated with improved physical health. Findings provide additional support for the use of ERRT in treating nightmares and related difficulties and improving sleep.

Journal of Clinical Sleep Medicine, 7(6), 622-631.

The Role of Cognitions in Imagery Rescripting for Posttraumatic Nightmares
Long, M.E., Davis, J.L., Springer, J., Elhai, J.D., Rhudy, J.L., Teng, E.J., Frueh, B.C. (2011)

Despite growing support for the use of imagery rescripting to treat posttraumatic nightmares (PTNMs), its underlying mechanisms have not been examined. This secondary data analysis piloted the proposal that modification of posttraumatic cognitions is a mechanism of change when using a manualized PTNM imagery rescripting intervention. Significant linear reductions in posttraumatic cognitions were observed from baseline through 6-month follow-up evaluations. Change in total negative cognitions was significantly correlated with change in posttraumatic stress disorder symptoms. Initial amount of change in subscale scores also predicted the amount of distal change observed at the 6-month follow-up. These findings provide preliminary evidence that trauma-related cognitions may improve over time as a result of imagery rescripting.

Journal of Clinical Psychology, 67(10), 1008–1016.

Imagery Rescripting and Exposure Group Treatment of Posttraumatic Nightmares in Veterans with PTSD
Long, M.E., Hammons, M.E., Davis, J.L., Frueh, B.C., Khan, M.M., Elhai, J.D., Teng, E.J. (2011)

This study details results of an open trial of a group psychological treatment for Veterans with posttraumatic stress disorder (PTSD) and chronic posttraumatic nightmares called “Imagery Rescripting and Exposure Therapy” (IRET). IRET is a variant of a successful imagery rescripting treatment for civilian trauma-related nightmares that was modified to address the needs of the Veteran population. Thirty-seven male U.S. Veterans with PTSD and nightmares attended 6 multicomponent group sessions. Findings indicated that the intervention significantly reduced frequency of nightmares and PTSD severity, as well as increased hours of sleep. Unlike the few open trials examining treatment of nightmares in Veterans, effect sizes in this study were similar to those that have been found in the civilian randomized controlled trial. These preliminary findings suggest that a nightmares treatment can be adapted to successfully reduce distress associated with combat Veterans’ chronic nightmares. Clinical and research implications are discussed.

Journal of Anxiety Disorders, 25(4), 531-535.

Multi-Component Treatment for Posttraumatic Nightmares in Vietnam Veterans: Two Case Studies
Wanner, J., Long, M.E., Teng, E.J. (2010)

Posttraumatic nightmares (PTNMs) are trauma-related distressing dreams that cause a person to wake up. PTNMs can be a devastating addition to the clinical picture of posttraumatic stress disorder (PTSD), because they can result in increased levels of PTSD symptoms and overall distress and decreased sleep; they are also often resistant to typical PTSD treatments. While specialized treatments have been developed and empirically examined in the civilian population, these treatments have not been thoroughly explored with the Veteran population, despite the fact that 50%-88% of Vietnam Veterans experience chronic PTNMs. This article presents two case reports involving Vietnam Veterans. These reports describe the initial investigation of a variant of a treatment that has been successful in treating chronic PTNMs in the civilian population and has been modified to meet the needs of the Veteran population. Analyses revealed that both Veterans reported moderate reductions in sleep disturbances over the course of treatment, as well as clinically significant reductions in PTSD and depressive symptoms across assessments. These preliminary findings provide encouraging data that warrant further study. Limitations and future research are discussed.

Journal of Psychiatric Practice, 16(4), 243-249.

Cognitive-Behavioral Treatment for Chronic Nightmares in Trauma-Exposed Persons: Assessing Physiological Reactions to Nightmare-Related Fear
Rhudy, J.L., Davis, J.L., Williams, A.E., McCabe, K.M., Bartley, E.J., Byrd, P.M., & Pruiksma, K.M. (2010)

Cognitive-behavioral treatments (CBTs) that target nightmares are efficacious for ameliorating self-reported sleep problems and psychological distress. However, it is important to determine whether these treatments influence objective markers of nightmare-related fear, because fear and concomitant physiological responses could promote nightmare chronicity and sleep disturbance. This randomized, controlled study (N=40) assessed physiological (skin conductance, heart rate, facial electromyogram) and subjective (displeasure, fear, anger, sadness, arousal) reactions to personally relevant nightmare imagery intended to evoke nightmare-related fear. Physiological assessments were conducted at pretreatment as well as 1-week, 3-months, and 6-months posttreatment. Results of mixed effects analysis of variance models suggested treatment reduced physiological and subjective reactions to nightmare imagery, gains that were generally maintained at the 6-month follow-up. Potential implications are discussed. ***Selected as one of the best publications in Sleep Medicine for 2011

Journal of Clinical Psychology, 66(4), 365-382.

A Combined Group Treatment for Nightmares and Insomnia in Combat Veterans: A Pilot Study
Swanson, L.M., Favorite, T.K., Horin, E., & Arnedt, J.T. (2009)

Insomnia and nightmares are hallmarks of posttraumatic stress disorder (PTSD). Sleep disturbances in PTSD negatively impact clinical course and functioning. In this open clinical trial, the preliminary effects of a combined treatment for insomnia and nightmares in combat veterans with PTSD were assessed. Ten combat veterans participated in a 10-session group treatment combining cognitive-behavioral therapy for insomnia with exposure, rescripting, and relaxation therapy. Participants maintained daily sleep and dream diaries and completed self-report measures of sleep quality and PTSD symptoms pre- and posttreatment. Participants reported improvements in sleep and nightmares following treatment. Future research using controlled designs to evaluate this treatment is warranted.

Journal of Traumatic Stress, 22(6), 639-642.

Physiological-Emotional Reactivity to Nightmare-Related Imagery in Trauma-Exposed Persons With Chronic Nightmares
Rhudy, J.L., Davis, J.L., Williams, A.E., McCabe, K.M., & Byrd, P.M. (2008)

Script-driven imagery was used to assess nightmare imagery-evoked physiological–emotional reactivity (heart rate, skin conductance, facial electromyogram, subjective ratings) in trauma-exposed persons suffering from chronic nightmares. Goals were to determine the efficacy of nightmare imagery to evoke physiological–emotional reactivity, correlates (mental health, nightmare characteristics) of reactivity, and consequences (sleep and health problems) of reactivity. Nightmare imagery resulted in significant reactivity relative to control imagery. No mental health variable (posttraumatic stress disorder status, depressive symptoms, dissociation) or nightmare characteristic (months experienced, frequency, similarity to trauma) was associated with reactivity level. However, nightmare imagery-evoked autonomic responses were associated with greater sleep disturbance and reported health symptoms, even when nightmare frequency was controlled. These results suggest nightmare-related autonomic reactions may contribute to sleep and health disturbance.

Behavioral Sleep Medicine, 6(3), 158-17

Randomized Clinical Trial for Treatment of Chronic Nightmares in Trauma-Exposed Adults
Davis, J.L., & Wright, D.C. (2007)

Nightmares and sleep disturbance are fundamental concerns for victims of trauma. This study examined the efficacy of a manualized cognitive–behavioral treatment (CBT) for chronic nightmares in trauma- exposed individuals via a randomized clinical trial. Participants were randomly assigned to a treatment group or wait-list control group, with 27 participants completing the treatment. At the 6-month follow- up assessment, 84% of treated participants reported an absence of nightmares in the previous week. Significant decreases were also reported in symptoms of depression and posttraumatic stress, fear of sleep, and number of sleep problems, while sleep quality and quantity improved. The present study adds to the growing literature indicating this brief CBT as a first-line treatment for trauma-exposed individuals with chronic nightmares.

Journal of Traumatic Stress, Vol. 20, No. 2, April 2007, pp. 123–133

Exposure, Relaxation, and Rescripting Treatment for Trauma-Related Nightmares
Davis, J.L., & Wright, D.C. (2006)

Trauma victims frequently report sleep disturbances, in- cluding nightmares, following traumatic events. Research indicates that nightmares are associated with the level and severity of other indices of distress. The recognition of the prominence of trauma-related nightmares, in prevalence and impact, has in part heightened efforts to de- velop and assess techniques to alleviate these difficulties. The majority of such previous efforts were predominantly case studies or uncontrolled group studies; however, recently several controlled studies have been conducted. The treatment with the most empirical support is generally called imagery rehearsal therapy (IRT). This treatment commonly involves relaxation procedures, limited exposure to the nightmare content, rewriting the content of the nightmare, and rehearsal of the altered content. This article provides a description of a modified version of IRT that incorporates all these techniques, with an enhanced exposure component and the addition of trauma themes and alteration of sleep habits. Guidelines for application with clients are outlined. A case study and case series were completed on this variant of IRT and a randomized clin- ical trial is currently underway.

Journal of Trauma & Dissociation, Vol. 7(1), 5-18.

Case Series Utilizing Exposure, Relaxation, and Rescripting Therapy: Impact on Nightmares, Sleep Quality, and Psychological Distress
Davis, J.L., & Wright, D.C. (2005)

Experiencing a traumatic event may initiate or exacerbate the occurrence of night- mares. Nightmares may impact sleep quality and quantity, posttraumatic stress symptoms, and depression. Recently, imagery rehearsal has gained attention in the treatment of trauma-related nightmares and is reported to be promising in the reduc- tion of nightmares. On the basis of the vast literature describing the therapeutic bene- fits of exposure techniques for anxiety-related problems, the treatment was modified to enhance the exposure component. This article presents a case series using this modified version of imagery rehearsal, Exposure, Relaxation, and Rescripting Therapy, with 1 male and 3 female participants. Overall, the participants treated re- ported a reduction in nightmare frequency and severity; 3 out of 4 participants also reported a reduction in posttraumatic stress and depression symptomotology and an increase in sleep quality and quantity. Clinical implications and future research direc- tions are discussed.

Behavioral Sleep Medicine, 3(3), 151–157.

Treatment of Nightmares Related to Post-traumatic Stress Disorder in an Adolescent Rape Victim
Davis, J.L., DeArellano, M., Falsetti, S.A., & Resnick, H.S. (2003)

Nightmares are a common response to a traumatic event and are one symptom of posttraumatic stress disorder. Although several treatments are currently available for the treatment of posttraumatic stress disorder, few studies report the efficacy of such treatments for nightmares. The current case involves the treatment of an adolescent rape victim who was involved in a treatment that targeted posttraumatic stress disorder and panic attacks. Following this treatment, the adolescent continued to report the experience of nightmares several times per week. The adolescent was then treated with a three-session cognitive behavioral treatment package involving relaxation procedures, exposure to the nightmare content, and rescripting the nightmare. At the one-month and three-month follow-up sessions, the patient reported a decrease in the intensity and frequency of nightmares. In this case it appeared necessary to include exposure and to target salient trauma-related themes in the rescripted dream.

Clinical Case Studies, Vol. 2 (4), 283-294.