Introduction 

The brain is the most crucial and mysterious organ of the body. Scientists have made significant discoveries in understanding brain activity. However, much remains unknown regarding how the brain processes information and the mechanisms of dreaming. Dreaming is a natural part of the sleep cycle, yet its purpose is unknown. External and internal factors can influence the type of dream a person can experience. These can manifest into pleasant dreams or nightmares.¹

Nightmares are disturbing dreams that are associated with negative feelings. They are common in children but can happen at any age. Occasional nightmares are nothing to worry about. However, there is a condition called nightmare disorder (recurring nightmares).¹ Nightmare disorder stems from unresolved emotional issues, past trauma or current stressors, such as anxiety or depression. This can become very distressing and can interfere with daily lives.²

To combat this, imagery rehearsal therapy (IRT) is used to lower the frequency and the intensity of nightmares. This article will examine how this technique is employed to rewrite and reprogram the narrative of nightmares.  

Understanding nightmare disorder

Nightmare disorder is when nightmares occur regularly. This disrupts sleep, disturbing daytime activities and even creates a fear of going to sleep. People with post-traumatic stress disorder (PTSD) are most vulnerable to this disorder. 

Nightmares are more likely to occur in the second half of the night, during the rapid eye movement (REM) cycle. People experience frequent nightmares, some even multiple times in a night. These episodes cause a person to wake up in a state of fear, making it difficult to return to sleep. The nightmares have these characteristics: 

• Dreams are vivid and upsetting, and become increasingly disturbing as they progress; a person can feel as though the dream is absolute 
• The themes can be disturbing, often linked to safety and survival 
• The dream leaves a person feeling anxious, afraid, sad,  angry or disgusted 
• Heart rates are high, and people often wake up in a state of perspiration 
• People can recall their dreams clearly after awakening 
• The distress from the dream prevents a person from falling back asleep¹

These factors separate occasional nightmares from nightmare disorder:

• Frequent occurrences 
• Distress continues into the day: anxiety, persistent fear, and bedtime anxiety
• Difficulty in concentration or memory throughout the day
• The images from the dream haunt the mind
• Low energy/ daytime fatigue 
• Problems in school/ work/ social situations 
• Impacts bedtime-related behaviours, e.g. developing a fear of the dark¹

What is imagery rehearsal therapy (IRT)?

IRT is a cognitive-behavioural treatment developed by Ian Marks in 1967. This technique helps reduce the frequency and intensity of nightmares. It does so by assisting the person in reimagining the nightmare into a less terrifying outcome. It aims to reprogram the nightmare so that, in the event of recurrence, it is easier to handle. This allows the individual to become desensitised to the original nightmare content.³

This therapy is based on the theory that nightmares are a “learned” sleep disorder, which leads to imagery distortion. This mental imagery escalates the nightmares from the status of a symptom to a disorder. Just as the nightmare was “learned”, it can be “unlearned”. IRT treatment depends on the individual’s case, which will determine the frequency and specificity of sessions. The method utilises the patient’s control to combat nightmares rather than relying on interpretations. This is a more sustainable solution, as it empowers the patient to overcome the nightmare.³

How IRT works: step-by-step process

IRT works through progressive inhibition of the target nightmare. The removal of unwanted imagery leaves gaps which are filled with positive mental images. Intervention works through the following steps:

1. Psychoeducation: The clinician walks the patient through the dream cycle and how nightmares arise from traumatic experiences. The patient is also taught proper sleep hygiene and the dysfunctional behaviours which maintain insomnia³
2. Learning: This step aims to teach the patient how to manage the nightmares by developing positive mental images. The clinician offers tools such as shapes, colours and movements for constructing pleasant images. This can be implemented through:
   1. Daydreaming - done with awareness 
   2. Self-talk - positive words with positive images or a story

This creates a supply of positive thoughts which can be used during imagery practice. This practice helps rewrite the patient’s script of their dreams. The therapists assess the patient’s level of mental imagery disturbance and their ability to construct new dream scripts. However, this process forces the patient to bring up upsetting images related to traumatic events, which can be overwhelming. Reinforcing self-regulation techniques is taught alongside to ensure the patient’s mental health. During this phase, the therapist assesses the patient’s ability to handle disturbing images before proceeding to the next stage.³

3. Selecting the disturbing nightmare: after developing coping techniques, the target nightmare is selected. The patient must relay the nightmare repeatedly to understand its roots. This can be emotionally disturbing, so patients are told to start from a less intense nightmare³
4. Re-evocation of selected nightmare: the patient writes down the target nightmare and is encouraged to include all details³
5. Nightmare rescripting: this is the defining stage of IRT. Here, the skills acquired during the learning phase are put into practice. The patient can now change the nightmare's storyline. Here, the entire theme of the nightmare can be altered into a positive dream. This is done by rescripting the end, the plot or any chosen part. The majority of patients created an alternative ending, while others decided to insert positive images or objects as reminders that they are dreaming. Some patients used distancing techniques, while others replaced terrifying images with pleasant ones, without altering the ending³
6. Rehearsal: This is the step to make all the hard work count. The patient must actively rehearse the rescripting of the nightmare for at least 10-20 minutes a day. It is crucial that only the new rewrite is practised and that the original nightmare is not recalled. Through constant repetition, the contents of the nightmare can be modified³

IRT has several variants which share the same principle of IRT but have some additional modifications. imagery rescripting and exposure therapy (IRET) employs relaxation techniques, such as progressive muscle relaxation, during the learning phase. Whereas exposure, relaxation, and rescripting therapy (ERRT) uses nightmare exposure techniques similar to imagery practice.³

Effectiveness and benefits of IRT

IRT has been helpful to adults who have undergone different types of PTSD. 

War veterans have had a significant reduction in nightmares through IRT. A study was conducted to evaluate its effectiveness. 90.9% reported improvements in sleep disturbances. 15.2% reported fewer nightmares. War veterans experience more repetitive nightmares which share specific characteristics. This creates a rough blueprint for IRT and allows the therapist to focus on particular triggers and nightmares, e.g. smells, sounds, emotions, etc. The results of IRT are long-lasting in war veterans, as they showed a significant reduction in nightmare frequency. The results remain even after treatment has ceased. This has helped war veterans manage their PTSD symptoms after concluding other forms of treatment, along with IRT.³

These results were obtained through several studies; however, one limitation is that the sample size was small, and there was no specific age range. Despite this, the results show an overall positive response to IRT. Further follow-up research in veterans should be carried out to support these studies.³

Victims of sexual abuse also suffer from PTSD. IRT can be used to reduce the distress caused by nightmares related to a traumatic event. Nightmares and sleep disturbances are prevalent in victims of abuse, which can lead to depressive episodes. A study was carried out with women who experienced abuse and their IRT treatment. The results showed that IRT alleviated distressing dreams and sleep disturbances. They recommend IRT for patients who are resistant to the idea of taking drugs or any pharmacological intervention. Furthermore, it was found that the reason IRT is so effective is due to the sense of power and control it gives patients over their minds. A study found that patients had a greater understanding of how to master negative imagery in their nightmares. As a result, they felt more confident in their ability to overcome their nightmare disorder. The usefulness of IRT extends to other PTSD symptoms, such as intrusive memories, flashbacks, or avoiding triggering stimuli.³

Challenges and considerations

Further studies should be conducted on a more diverse population. The age ranges must be categorised, and the underlying factors must also be accounted for. Furthermore, follow-up assessments should be conducted after several months. This is to ensure that the re-scripting is focused.³

Conclusion

IRT is currently the most effective treatment for nightmare disorder as it directly targets the distressing contents of the nightmares. It identifies the negative feelings associated with the nightmares and reverses their impact on the patient. This gives the patient a boost in self-confidence and a sense of mastery over their mind. However, further studies are required to understand dream scenarios and how to intervene effectively. 

Summary

• Nightmare Disorder involves frequent, disturbing dreams that impair sleep and well-being
• Imagery Rehearsal Therapy (IRT) is a cognitive-behavioural technique designed to reduce nightmares by rewriting them
• IRT is based on the idea that changing the content of a nightmare while awake can reduce its emotional power
• Steps of IRT include:
  • Selecting a recurring nightmare
  • Recalling and documenting it in detail
  • Rewriting it with a new, non-distressing ending
  • Rehearsing the new version mentally regularly
• IRT benefits:
  • Reduces nightmare frequency and intensity
  • Improves sleep quality
  • Empowers individuals to feel more in control
  • Works for various ages and trauma types, including PTSD
• It is safe, non-invasive, and often medication-free
• Challenges include emotional difficulty at first and the need for consistent practice
• Best results often occur with therapist guidance, though self-guided options exist
• Conclusion: IRT is a hopeful, empowering approach to reclaiming peaceful sleep from the grip of nightmares