Gellis and Gehrman [66] conducted a pilot study of five sessions of CBT-I in eight veterans with chronic PTSD. The authors found that insomnia severity and sleep parameters measured with the sleep diary demonstrated significant improvements. Objectively measured sleep with actigraphy (small, wrist-worn devices that monitor movement and provide estimates of sleep continuity) did not show improvements. Although statistically significant improvements in depression were observed, there were no improvements in nightmares or other PTSD symptoms. The authors hypothesize that although subjectively reported sleep improved, the presence of PTSD and nightmares may limit the effectiveness of CBT-I in individuals with PTSD.

In an RCT with 45 veterans with PTSD, Talbot and colleagues [67] compared CBT-I with a monitor-only waitlist control. They found that CBT-I improved insomnia among these veterans with PTSD. Large changes were found with the sleep diary, polysomnography with regard to total sleep time, several other self-report sleep measures, as well as social and work functioning. Although PTSD improved it did not improve more than the monitoring group. All participants were required to be enrolled in treatment for PTSD (medications or psychotherapy), and so the impact of CBT-I alone is unclear.

More recently, researchers have proposed that treatment approaches that combine elements of nightmare treatments (i.e., exposure, rescripting, and imagery rehearsal) and CBT-I (i.e., sleep restriction ) may be optimal for treating sleep disturbances in trauma-exposed adults. One case study [68], one noncontrolled trial [51], and a randomized parallel group experiment [69] of IRT combined with CBT-I in veterans have been reported. Another study implemented CBT-I and included IRT only as an adjunctive intervention for some participants [70] (see Table 24.1). In the case study [68], a 69-year-old Vietnam veteran who had been experiencing nightmares for 35 years completed two sessions of CBT-I followed by three sessions of IRT . At the end of treatment, his nightmare frequency reduced from 17 per week to 5 per week. He also reported decreased nightmare intensity and improved sleep. In an open trial, Harb et al. [51] examined a six-session treatment protocol that combined CBT-I and IRT in seven veterans of the Iraq war. The treatment included three sessions of psychoeducation, progressive muscle relaxation, and sleep hygiene (including stimulus control) followed by three sessions of IRT (one session for writing the target nightmare, one session for brainstorming changes to the nightmare, and one session for rescripting the nightmare). Overall, improvements were found in nightmare frequency, sleep quality, and PTSD symptom severity. Further, the authors divided the sample into responders (n = 4) and nonresponders (n = 3). The authors noted that the nonresponders were experiencing certain issues that may have impacted treatment outcome including pending redeployment, traumatic brain injury, alcohol use, nightmares of perpetration, and guilt. Thus, research is needed to examine potential predictors of response to IRT.

In the randomized parallel group study [69], 22 veterans with PTSD from a variety of eras were randomized to either the treatment condition (three sessions of CBT-I followed by three sessions of IRT) or to care as usual (including a variety of mental health treatments such as medication management/supportive therapy and unspecified individual therapy sessions). From baseline to immediate posttreatment, veterans in the CBT-I with IRT condition demonstrated greater improvements in nightmare frequency, sleep parameters, insomnia severity, sleep quality, and PTSD symptoms than the control group, providing additional support for the efficacy of treatments targeting sleep disturbances in veterans with PTSD.

ERRT also has been combined with CBT-I to treat trauma-related nightmares. From its inception, the ERRT manual has included components to improve sleep directly, including relaxation training (e.g., diaphragmatic breathing and progressive muscle relaxation), sleep hygiene, and stimulus control [71, 72]. However, participants typically have been asked to select any poor sleep hygiene habit to modify during the course of treatment and any positive sleep hygiene habit to maintain. Thus, stimulus control and sleep restriction, which are considered integral components of CBT-I [65], are not always selected as an integral component of ERRT .

Swanson et al. [73] modified ERRT to include five sessions of CBT-I (including stimulus control and sleep restriction for every patient) prior to nightmare rescripting for a total of ten sessions of therapy. This protocol was evaluated in an open trial with a sample of nine combat veterans with PTSD (see Table 24.1). Results demonstrated an average reduction in nightmares per week of 50% and an average reduction in total nightmare distress of 46%. Interestingly, data indicate a substantial decrease in nightmare frequency prior to implementation of exposure or rescription of the nightmare followed by continuing improvements. Furthermore, the average insomnia ratings were in the subthreshold range at the conclusion of treatment. However, PTSD symptom ratings did not demonstrate a significant decrease. Further research is needed to determine the optimal combinations of treatment components and to determine for which symptom presentations the treatments are needed .

Another study conducted by Margolies et al. [70] randomized 40 veterans with PTSD into either CBT-I with adjunctive IRT or a waitlist control . IRT was implemented with 13 participants who reported nightmares but only 6 of those participants opted to continue IRT in subsequent sessions. Veterans who were placed into the CBT-I/IRT group reported significant increases in overall sleep quality and decreased nighttime PTSD symptoms, PTSD symptom severity, and depressed mood when compared to the control. These results support the use of sleep-based treatments for individuals experiencing sleep and PTSD disturbances and support the notion that sleep disturbances may be exacerbating symptoms of PTSD .

Few studies have examined treatment approaches that combine sleep interventions with broader PTSD treatments. Because nightmares and problems falling and staying asleep are symptoms of PTSD, it is thought that these symptoms will remit along with the treatment of the constellation of re-experiencing, avoidance, and hyperarousal symptoms. As discussed further below, this approach has been the topic of some debate.