Background: Several cognitive-behavioral techniques are effective in reducing nightmare frequency, but the therapeutic factor (e.g. cognitive restructuring, systematic desensitization) remains unclear. The aim of this study was to compare the nightmare treatments imagery rehearsal therapy (IRT), exposure, and recording (keeping a diary) – in a self-help format – with a waiting list. Methods: Participants were recruited through a Dutch nightmare website. After completion of the baseline questionnaires, 399 participants were randomly assigned to a condition, received a 6-week self-help treatment (or were placed on the waiting list), and filled out the post-treatment measurements 11 weeks after baseline. Results: Compared to the waiting list, IRT and exposure were effective in ameliorating nightmare frequency and distress, subjective sleep quality, anxiety (after imagery rehearsal), and depression (after exposure; Δd = 0.25–0.56). Compared to recording, IRT reduced nightmare frequency while exposure reduced nightmare distress (Δd = 0.20–0.30; p < 0.05). The recording condition was more effective compared to the waiting list in ameliorating nightmare frequency, nightmare distress, and subjective sleep quality (Δd = 0.19–0.28; p < 0.05). IRT had a more rapid reduction on the diary compared to exposure and recording. Conclusions: IRT and exposure appear equally effective in ameliorating nightmare complaints. Exposure to nightmare imagery may function as the crucial therapeutic factor; however, cognitive restructuring may be a useful addition to increase immediate effects.

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