The Impact of Prolonged Exposure on Sleep and Enhancing Treatment Outcomes With Evidence-Based Sleep Interventions: A Pilot Study

Elizabeth M. Walters, Melissa M. Jenkins, Carla M. Nappi, Jacob Clark, July Lies, Sonya B. Norman, Sean P. A. Drummond

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40 Citations (Scopus)


Objective: Insomnia and nightmares are central features of posttraumatic stress disorder (PTSD). However, often they are inadequately assessed and ineffectively resolved following gold-standard PTSD treatment. Here we: (a) evaluate effects of prolonged exposure (PE) on subjectively measured sleep and (b) present pilot results of an examination of whether adding sleep interventions (imagery rehearsal therapy [IRT] and cognitive-behavioral therapy for insomnia [CBT-I]) to PE improves treatment response, relative to PE alone, for night- and/or daytime PTSD symptoms among returning U.S. veterans and postdeployment personnel. Method: In a parallel-groups, randomized controlled trial, participants received 12 sessions of PE followed by IRT (5 weeks) and CBT-I (7 weeks) or PE followed by 12 weeks supportive care therapy (SCT). Results: PE did not improve sleep to a clinically meaningful degree, despite significant improvements in both Clinical Administered PTSD Scale and PTSD Checklist. Enhancing treatment with IRT/CBT-I led to greater improvements in insomnia (diary-recorded sleep efficiency) symptoms with large effect size, relative to SCT (p = .068, d = 1.07). There were large improvements in nightmare frequency relative SCT that did not reach statistical significance (p = .11, d = 0.90). Moreover, there was small improvement in daytime symptoms (Clinical Administered PTSD Scale) that did not reach statistical significance (p = .54, d = .31). Conclusion: The addition of targeted, validated sleep treatment improves effects of PE and improves nighttime symptoms. Thus, evidencebased sleep treatment should be considered in comprehensive PTSD treatment.

Original languageEnglish
Pages (from-to)175-185
Number of pages11
JournalPsychological Trauma: Theory, Research, Practice, and Policy
Issue number2
Publication statusPublished - Feb 2020


  • Cognitive-behavioral therapy for insomnia
  • Imagery rehearsal therapy
  • Prolonged exposure
  • Sleep
  • Veterans

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