Treatment of PTSD: a comparison of imaginal exposure with and without imagery rescripting

Open Trial of a Brief Imagery-Based Stabilization Psychotherapy for Adults with Acute Posttraumatic Stress Disorder

PURPOSE

Early intervention after trauma is needed for reduction in clinical distress and prevention of chronic posttraumatic stress disorder (PTSD). This study describes findings from an open pilot trial of a brief stabilization psychotherapy based on imagery techniques for adults with acute PTSD (i.e., within 3 months of onset).

MATERIALS AND METHODS

Four sessions of 60-minute individual psychotherapy were conducted on 18 participants with PTSD within 3 months after accidents, 15 of whom completed the treatment. The clinician-administered PTSD scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the Hamilton Depression and Anxiety Rating Scales, and self-questionnaires were administered at pre-treatment, post-treatment, and 6-month follow-up.

RESULTS

Eight (53.3%) of the 15 patients at post-treatment and 8 of the 9 patients at 6-month follow-up did not meet the DSM-5 criteria for PTSD. Reliable change of PTSD symptoms after treatment was observed in 6 of 15 (45.0%) patients at post-treatment and in 4 of 9 (45.0%) patients after 6 months. There was a significant decrease in PTSD, depression, anxiety, and impaired quality of life scores after treatment, and these gains were maintained after 6 months. No cases of exacerbated PTSD symptoms were observed among completers and non-completers.

CONCLUSION

Our findings suggest that brief stabilization sessions are safe treatment options for acute PTSD (KCT0001918).

An imagery rescripting based intervention in children and adolescents who endured a negative life event: A pilot study, satisfaction and feasibility survey

BACKGROUND AND OBJECTIVES

ImRs, a technique targeting distressing mental images, has shown promise in adult psychiatric treatment. Initial research indicates positive outcomes in children, with potential for reducing mental health care burden. This pilot study examined the use of Imagery Rescripting (ImRs) as an intervention for children who have experienced negative life events. We aimed to assess short-term emotional changes, participant satisfaction, and the feasibility of a larger-scale ImRs intervention for children.

METHODS

We employed a pre-posttest within-group design, and included 35 children (ages 5-18) who experienced negative life events, as well as 12 coaches. ImRs targeted distressing images related to negative events. Measurement tools included Visual Analogue Scales for distress and emotions, along with satisfaction surveys for both children and coaches. The feasibility of a larger-scale study was also explored through a coach questionnaire.

RESULTS

We found significant short-term improvements for all emotional states, with large effects for anxiety, sadness, and happiness, and a moderate effect for anger. Children reported fair levels of satisfaction with the intervention's acceptability and complexity. Coaches expressed high levels of satisfaction with the intervention as a whole and with its characteristics. Coaches were also strongly motivation for future, more in-depth research. An important limitation of this pilot study was the lack of a control group. In light of the promising results, more extensive studies with diagnostic information, multiple measures, and follow-up assessments are warranted.

CONCLUSION

Altogether, imagery rescripting based interventions seem a promising venue for children who experienced negative events.

Posttraumatic stress disorder following childhood sexual and physical abuse: a study protocol for an 11-week randomised controlled trial comparing imaginal exposure and imagery rescripting

Background: There is a vast amount of evidence supporting the effectiveness of trauma-focused cognitive-behavioral therapy in treating posttraumatic stress disorder (PTSD). However, it remains unclear which specific treatment is most effective for patients with PTSD following childhood sexual and physical abuse (CSPA). Although Imaginal Exposure (IE) has proven highly effective in treating PTSD and is widely acknowledged as a standard method, Imagery Rescripting (IR) may be more suitable for CSPA-related PTSD. IR not only addresses fear but also targets other emotions and cognitions associated with childhood maladaptive schemas. Preliminary findings suggest lower drop-out rates for IR compared to IE, but no Randomized Controlled Trial (RCT) currently assesses the effectiveness of IR for CSPA-related PTSD.Objective: This article presents a study protocol designed to investigate the optimal treatment (IE or IR) for individuals with CSPA-related PTSD and explore predictors of treatment success.Method: In our study protocol, we suggest the inclusion of 173 patients (N = 64 in IR, N = 64 in IE, and N = 45 in the waitlist condition). The therapy procedures for both IE and IR will consist of 16 sessions lasting 90 min each, with treatment durations of 11 weeks. Measurements take place at baseline, at start of treatment, 11 weeks after the start of treatment (after 16 sessions) and at follow-up at 26 weeks after the last session. A mixed regression will be used to compare the three active conditions before and after measurement.Results: This article serves as a study protocol. The results are not yet available but they will be presented in a subsequent article.Conclusion: This study protocol outlines a RCT which will be the first to provide information on the effectiveness of IR versus IE versus a control group in CSPA-related PTSD.Trial registration: Netherlands Trial Register NTR 4817. Registered 26 September 2014.

Self-guided imagery rescripting for worry images: A preliminary experimental investigation

BACKGROUND

Mental images of feared events are overactive and intrusive in generalized anxiety disorder (GAD). Imagery rescripting involves integration of positive or neutral imagery and corrective information into images to facilitate emotional processing, reduce imagery intrusions, and re-structure underlying schema. Yet only one known study has applied the technique to treatment of worry. The present study aimed first to examine the relationship between trait worry and properties of future-oriented worry images, and second to examine the efficacy of a self-guided imagery rescripting intervention in improving individuals' response to their worries.

METHODS

Participants recruited through Amazon Mechanical Turk (N = 365) identified their major worry and wrote the script of a worst-case scenario mental image. Participants were randomized to three conditions: re-writing the same worry image script (exposure), or writing scripts of either one or three positive alternative future-oriented images (rescripting conditions).

RESULTS

In preliminary analyses, trait worry negatively predicted participants' ratings of worry images, including valence and ability to cope, and positively predicted distress, anticipated cost, and belief in their negative meaning. In experimental analyses, linear mixed-effects models revealed anxious response and cognitive appraisal of the threat were significantly lower among participants allocated to rescripting relative to exposure. There was no effect of rescripting type.

CONCLUSIONS

This investigation demonstrated the impact of a future-oriented imagery rescripting task on anxiety and cognitive biases associated with real worries in an unselected sample. Results may contribute to the development of imagery rescripting interventions for GAD.

Working mechanisms of imagery rescripting (ImRs) in adult patients with childhood-related PTSD: a pilot study

Background: Imagery rescripting (ImRs) has shown to be an effective treatment for posttraumatic stress disorders (PTSD) resulting from childhood-related trauma. The current theory is that the change of meaning of the trauma memory is central to the treatment. Several authors have suggested that the expression of needs, feelings and actions may act as potential healing factors, but little specific research aimed at (in)validating this hypothesis has been done so far.Objective: In this study we investigated to what extent the expression of inhibited action tendencies and the fulfilling of needs lead to the reduction of PTSD symptoms in clients with early childhood trauma.Method: Recordings of 249 therapy sessions of 24 ImRs treatments were rated with an observation instrument developed for this purpose, after which the scores were related to pre and posttreatment symptoms, assessed with the Impact of Events Scale-Revised (IES-R).Results: Scores on the IES-R decreased from pretreatment to posttreatment. The two subscales of the NATS (At-scale and N-scale)significantly predicted the posttreatment scores on the IES-R after controlling for the influence of pretreatment IES-R scores: the better the expression of inhibited action tendencies and the better the fulfilling of needs, the lower the symptoms after treatment.Conclusions: This pilot study on the underlying mechanisms of ImRs in PTSD treatment has shown that the expression of action tendencies and fulfilling basic needs during ImRs are associated with a decrease in PTSD symptoms after treatment, and that actions and basic needs cannot be viewed separately. Follow-up research could focus on which of the six domains of the Needs and Action tendencies Scale (NATS) has the greatest effect on the reduction of PTSD symptoms. With this information we can further improve the ImRs protocol.

The working mechanisms of imagery rescripting and eye movement desensitization and reprocessing: Findings from a randomised controlled trial

We studied the mechanisms of eye movement desensitization and reprocessing (EMDR) and imagery rescripting (ImRs). We hypothesized that EMDR works via changes in memory vividness, that ImRs works via changes in encapsulated beliefs (EB), and that both treatments work via changes in memory distress. Patients (N = 155) with childhood-related posttraumatic stress disorder (Ch-PTSD) received 12 sessions of EMDR or ImRs. The vividness, distress, and EB related to the index trauma were measured with the Imagery Interview. PTSD severity was assessed with the Impact of Events Scale-Revised and the Clinician-Administered PTSD Scale for DSM-5. We conducted mixed regressions and Granger causality analyses. EMDR led to initially stronger changes in all predictors, but only for distress this was retained until the last assessment. No evidence for vividness as a predictive variable was found. However, changes in distress and EB predicted changes in PTSD severity during ImRs. These findings partially support the hypothesized mechanisms of ImRs, while no support was found for the hypothesized mechanisms of EMDR. Differences in the timing of addressing the index trauma during treatment and the timing of assessments could have influenced the findings. This study provides insight into the relative effectiveness and working mechanisms of these treatments.

Imagery rescripting and cognitive restructuring for inpatients with moderate and severe depression - a controlled pilot study

BACKGROUND

This controlled pilot study investigates the effect of the combined use of cognitive restructuring (CR) and imagery rescripting (IR) compared to treatment as usual among inpatients with moderate and severe depression. Alongside expert ratings and self-report tools, fitness wristbands were used as an assessment tool.

METHODS

In addition to the standard inpatient care (SIC) program, 33 inpatients with moderate and severe depression were randomly assigned to an intervention group (two sessions of IR and CR) or an active treatment-as-usual (TAU) control group (two sessions of problem-solving and build-up of positive activity). Depression severity was assessed by the Hamilton Depression Rating Scale-21 (HDRS-21), the Beck Depression Inventory-II (BDI-II), and as a diagnostic adjunct daily step count via the Fitbit Charge 3™. We applied for analyses of HDRS-21 and BDI-II, 2 × 2 repeated-measures analysis of variance (ANOVA), and an asymptotic Wilcoxon test for step count.

RESULTS

The main effect of time on both treatments was η2 = .402. Based on the data from the HDRS-21, patients in the intervention group achieved significantly greater improvements over time than the TAU group (η2 = .34). The BDI-II data did not demonstrate a significant interaction effect by group (η2 = .067). The daily hourly step count for participants of the intervention group was significantly higher (r = .67) than the step count for the control group.

CONCLUSIONS

The findings support the utilization of imagery-based interventions for treating depression. They also provide insights into using fitness trackers as psychopathological assessment tools for depressed patients.

TRIAL REGISTRATION

The trial is registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien) under the registration number: DRKS00030809.

The effectiveness of two novel approaches to prevent intrusions: A pilot study comparing Tetris_dualtask and imagery rescripting to control

BACKGROUND AND OBJECTIVES

Post-traumatic stress disorder (PTSD) is a global health problem. Although effective treatments for it exist, early interventions that prevent PTSD from developing are lacking. The aim of this pilot analogue trauma study was to compare the effects of two potential early intervention strategies, namely Tetris_dualtask and imagery rescripting (IR) to a no-intervention control group on intrusion frequency and the vividness and emotionality of aversive film memory.

METHODS

Sixty healthy students were subjected to the trauma film paradigm and randomly allocated to either: Tetris_dualtask, IR or no-intervention. Main outcomes were the number of film-related intrusions at one week and vividness and emotionality ratings of the most aversive film memory. Secondary outcomes were PTSD-like symptoms, intrusion intensity, and explicit film memory.

RESULTS

The Tetris_dualtask group reported significant fewer intrusions compared to the no-intervention group; whereas the IR group did not. No effect was found on vividness and emotionality ratings, PTSD-like symptoms, intrusion intensity, and explicit memory.

LIMITATIONS

The sample size was small, and analogue trauma in healthy individuals was examined, thus generalizability may be limited. Also, to increase comparability between interventions, the duration of Tetris_dualtask and IR was standardized. As a result, the IR intervention was shorter compared to other studies, which might have decreased its efficacy.

CONCLUSIONS

The results of this pilot study suggest that playing Tetris during retrieval of traumatic images, might hold potential as an early intervention strategy to reduce intrusions in the early aftermath of trauma and adversity. However, future large-scale replication research is needed.

The effect of aggressive fantasizing on aggressive inclinations: Moderating effects of dispositional anger expression

Experiencing victimization or mistreatment often induces feelings of anger. The catharsis hypothesis suggests that venting anger may aid in alleviating these negative emotions. Although this hypothesis has faced criticism, therapeutic interventions rooted in catharsis are employed to assist victims in managing their anger. One notable application of the catharsis principle in psychotherapeutic practice with victims involves engaging in aggressive fantasies: Victims who harbor aggressive fantasies against their offenders are supported in working with these fantasies to navigate the complex emotions arising from their victimization. Research investigating the effects of aggressive fantasizing on victims has yielded inconsistent findings, with some studies indicating positive and others suggesting negative outcomes. Herein, we examine whether (instructed) aggressive fantasizing diminishes (catharsis hypothesis) or heightens (escalation hypothesis) subsequent aggressive inclinations compared to non-aggressive fantasizing. Additionally, the moderating role of victims' dispositional tendencies to express anger, specifically Anger Expression-out and Anger Expression-control, in the relationship between aggressive fantasizing and aggressive inclinations was examined. We recruited individuals (N = 245) who had experienced victimization through highly unfair treatment and instructed them to imagine confronting their wrongdoer using either aggressive or non-aggressive communication. Participants then reported their aggressive inclinations. Data supported the escalation hypothesis, revealing that aggressive fantasizing amplifies subsequent aggressive inclinations. Importantly, individuals with higher Anger Expression-out demonstrated greater susceptibility to this effect; whereas, Anger Expression-control did not moderate the link between aggressive fantasizing and inclinations. These findings further challenge the catharsis hypothesis and underscore the role of dispositional anger expression tendencies on the effects of aggressive fantasizing.

Efficacy of an internet-based written imagery rescripting intervention for survivors of institutional childhood abuse - A randomized controlled trial

BACKGROUND

Institutional childhood abuse can have a long-term impact on the survivors' mental health, however, treatment for this group is limited and not always accessible. An internet-based intervention was developed, with the aim to reduce psychological sequelae relating to institutional abuse.

OBJECTIVE

This study aimed to examine the efficacy of an online imagery rescripting intervention for survivors of institutional abuse, through assessing symptoms of depression, anxiety, PTSD, and CPTSD.

PARTICIPANTS AND SETTING

Seventy-two adult survivors of institutional childhood abuse in the former German Democratic Republic were randomized either to the intervention (n = 38) or to the waitlist condition (n = 34). The intervention consisted of 10 modules, based on written imagery rescripting, and involved asynchronous therapist contact.

METHODS

Primary outcomes included symptoms of depression (PHQ-9), anxiety (GAD-7), PTSD (ITQ), and CPTSD (ITQ DSO). The intervention condition was assessed at baseline, post-intervention, 3-, and 6-month follow-up.

RESULTS

Intention-to-treat analyses revealed a significant symptom reduction from baseline to post-assessment with medium to large effects for all main outcomes (d = 0.45 to d = 0.76), in favor of the intervention condition. Significant interactions between condition (intervention vs. wailist) and time (baseline vs. post-assesment) were revealed for all main outcomes (p < .001 to p = .024). The effects were maintained at follow-up.

CONCLUSIONS

The results suggest online writing-based imagery rescripting as a promising treatment option for adults formerly institutionalized in residential care. Future research is needed to explore its effectiveness for other groups of patients suffering from abuse and neglect.

Effects of imagery rescripting and imaginal exposure on voluntary memory

Trauma-focused imagery-based interventions, such as Imagery Rescripting (ImRs) and Imaginal Exposure (ImE), are effective in reducing involuntary re-experiencing in PTSD. However, it has been suggested that they may impair voluntary memory. This study investigates whether ImRs and ImE distort voluntary memory of an analogue trauma. We presented a trauma film to N = 120 healthy participants (Session 1) and randomly allocated them to one of two intervention conditions (receiving one session of ImRs or ImE) or to a no-intervention control condition (NIC) afterwards (Session 2). Voluntary memory was assessed using a free recall (Sessions 2 and 3), and a cued recall as well as a recognition task (both Sessions 3 and 4). The ImRs and ImE groups did not differ from NIC in the cued recall task and the recognition task. However, ImE (compared to ImRs and NIC) led to an increase in correct reported details in the free recall. In sum, the current findings do not suggest that ImRs or ImE impair voluntary memory.

A brief treatment for veterans with PTSD: an open-label case-series study

Introduction

Despite the positive outcomes observed in numerous individuals undergoing trauma-focused psychotherapy for PTSD, veterans with this condition experience notably diminished advantages from such therapeutic interventions in comparison to non-military populations.

Methods

In a preliminary study we investigated the efficacy of an innovative treatment approach in a small sample of veterans (n = 7). Recognizing that accessing and targeting trauma memory in veterans with PTSD may be more challenging compared to other patient populations, we employed unique and personalized retrieval cues that engaged multiple senses and were connected to the context of their trauma. This was followed by a session focused on memory reconsolidation, which incorporated both psychological techniques (i.e., imagery rescripting) and a pharmacological component (i.e., 40 mg of propranolol).

Results

The findings from this small-scale case series cautiously indicate that this brief intervention, typically consisting of only one or two treatment sessions, shows promise in producing significant effects on symptoms of PTSD, distress and quality of life.This is particularly noteworthy given the complex symptomatology experienced by the veterans in this study.

Conclusion

To summarize, there are grounds for optimism regarding this brief treatment of combat-related PTSD. It appears that the potential for positive outcomes is far greater than commonly believed, as demonstrated by the encouraging results of this pilot study.

Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood

BACKGROUND

Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults.

OBJECTIVES

To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood.

SEARCH METHODS

In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches.

SELECTION CRITERIA

Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD).

AUTHORS' CONCLUSIONS

Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

Efficacy of imagery rescripting in treating mental disorders associated with aversive memories - An updated meta-analysis

Imagery rescripting (ImRs) is frequently applied to treat different psychological complaints. We conducted an updated meta-analysis based on randomised controlled trials on the efficacy of ImRs for mental disorders associated with aversive memories. Medline, PsycInfo, and Web of Science were searched up to May 2023. Seventeen trials were included with a total of 908 participants (417 in the ImRs condition), suffering from posttraumatic stress disorder, anxiety disorders, depression, or eating disorders. Random effect models yielded an overall effect of g = 0.68 (95 % CI 0.18 to 1.18; k = 7) compared to passive controls (mostly waitlist). The effect compared to (prolonged) exposure, cognitive restructuring, and EMDR was non-significant (g = -0.01; 95 % CI -0.18 to 0.15; k = 11). Follow-up assessments indicated a long-term treatment effect. Results suggest that ImRs can effectively treat a variety of psychological disorders and produce similar treatment effects as evidence-based interventions. Limitations include the bounded number of included trials for each mental disorder. The meta-analysis was registered on PROSPERO (CRD42020220696) and received no funding.

A transdiagnostic meta-analysis of acute augmentations to psychological therapy

At least half of all patients with mental health disorders do not respond adequately to psychological therapy. Acutely enhancing particular biological or psychological processes during psychological therapy may improve treatment outcomes. However, previous studies are confined to specific augmentation approaches, typically assessed within single diagnostic categories. Our objective was to assess to what degree acute augmentations of psychological therapy reduce psychiatric symptoms and estimate effect sizes of augmentation types (for example, brain stimulation or psychedelics). We searched Medline, PsycINFO and Embase for controlled studies published between database inception and 25 May 2022. We conducted a preregistered random-effects meta-analysis (PROSPERO CRD42021236403). We identified 108 studies (N = 5,889). Acute augmentation significantly reduced the severity of mental health problems (Hedges' g = -0.27, 95% CI: [-0.36, -0.18]; P < 0.0001), particularly for the transdiagnostic dimensions 'Fear' and 'Distress'. This result survived a trim-and-fill analysis to account for publication bias. Subgroup analyses revealed that pharmacological, psychological and somatic augmentations were effective, but to varying degrees. Acute augmentation approaches are a promising route to improve outcomes from psychological therapy.

A systematic review and meta-analysis of the effect of cognitive interventions to prevent intrusive memories using the trauma film paradigm

There is an unmet need for effective early interventions that can relieve initial trauma symptoms and reduce symptoms of posttraumatic stress disorder (PTSD). We evaluated the efficacy of cognitive interventions compared to control in reducing intrusion frequency and PTSD symptoms in healthy individuals using the trauma film paradigm, in which participants view a film with aversive content as an experimental analogue of trauma exposure. A systematic literature search identified 41 experiments of different cognitive interventions targeting intrusions. In the meta-analysis, the pooled effect size of 52 comparisons comparing cognitive interventions to no-intervention controls on intrusions was moderate (g = -0.46, 95% CI [-0.61 to -0.32], p < .001). The pooled effect size of 16 comparisons on PTSD symptoms was also moderate (g = -0.31, 95% CI [-0.46 to -0.17], p < .001). Both visuospatial interference and imagery rescripting tasks were associated with significantly fewer intrusions than controls, whereas verbal interference and meta-cognitive processing tasks showed nonsignificant effect sizes. Interventions administered after viewing the trauma film showed significantly fewer intrusions than controls, whereas interventions administered during film viewing did not. No experiments had low risk of bias (ROB), 37 experiments had some concerns of ROB, while the remaining four experiments had high ROB. To the best of our knowledge, this is the first meta-analysis investigating the efficacy of cognitive interventions targeting intrusions in non-clinical samples. Results seem to be in favour of visuospatial interference tasks rather than verbal tasks. More research is needed to develop an evidence base on the efficacy of various cognitive interventions and test their clinical translation to reduce intrusive memories of real trauma.

The treatment of PTSD in refugees and asylum seekers using imagery rescripting within an NHS setting

BACKGROUND

Refugees and asylum seekers present with high levels of post-traumatic stress disorder (PTSD), whilst little research has been conducted to assess the effectiveness or acceptability of psychological interventions for this group. Imagery rescripting is effective in reducing distressing intrusive memories within a range of conditions. The current study evaluates this approach for the treatment of PTSD in refugees and asylum seekers within a UK NHS service.

AIMS

To evaluate the clinical outcomes of using imagery rescripting for the treatment of PTSD in UK-based refugees and asylum seekers.

METHOD

Ten adult service-users from an NHS specialist service with a primary diagnosis of PTSD were recruited as part of routine service delivery. A multiple baseline design was used with participants randomly allocated to a baseline varying from 5 to 9 weeks. A baseline wait-period was followed by up to five sessions of psychoeducation and treatment preparation, in turn followed by up to 10 sessions of imagery rescripting. The Post-traumatic Symptom Scale (PSS) and Physical Health Questionnaire-9 (PHQ-9) were collected every week during baseline, at end of treatment and weekly for 5 weeks after treatment, and again at 12-week follow-up. Data were analysed with mixed regression.

RESULTS

Results indicate a significant improvement both in PTSD symptoms and mood, and that this was attributable to the imagery rescripting phase of the intervention, and not the passage of time or non-specific therapy factors.

CONCLUSIONS

Evidence indicates imagery rescripting to be a safe and effective treatment choice for PTSD in refugees and asylum seekers.

The effect of imagery rescripting on core beliefs and eating disorder symptoms in a subclinical population

BACKGROUND AND OBJECTIVES

This study compared the effect of imagery rescripting focusing on self-compassion, imagery rescripting focusing on mastery, and a positive memory control condition on (1) emotional responses towards the memory (one day after), (2) changes in the believability of negative core beliefs, and dysfunctional eating behaviors (one week after) in individual at risk for developing an eating disorder.

METHODS

Female participants (N = 69) were allocated to one of three conditions: ImRs focusing on self-compassion (N = 24), ImRs focusing on self-mastery (N = 23), and positive memory control condition (N = 22). Participants in the ImRs conditions received a 20-min self-guided ImRs intervention, whereas participants in the control condition received a 20-min self-guided task focusing on an unrelated positive memory.

RESULTS

The experimental manipulation successfully induced the use of self-compassion and mastery strategies in the respective imagery rescripting condition. However, our data show that a single 20-min session of self-guided imagery rescripting focusing on compassion and/or mastery has no effect on the emotional response towards the aversive memory or in the change of core beliefs and eating behaviors at follow up.

LIMITATIONS

We discuss potential reasons for the null findings, including the use of a single imagery rescripting session, the sample size and the measurement of manipulation checks.

CONCLUSION

Future studies are needed to rule out methodological explanations for the null results. These findings may be of value for the development of future experimental lab paradigms which aim to evaluate the causal effects and working mechanisms of imagery rescripting.

Therapeutic interventions impact brain function and promote post-traumatic growth in adults living with post-traumatic stress disorder: A systematic review and meta-analysis of functional magnetic resonance imaging studies

Introduction

The present systematic review and meta-analysis explores the impacts of cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and prolonged exposure (PE) therapy on neural activity underlying the phenomenon of post-traumatic growth for adult trauma survivors.

Methods

We utilized the following databases to conduct our systematic search: Boston College Libraries, PubMed, MEDLINE, and PsycINFO. Our initial search yielded 834 studies for initial screening. We implemented seven eligibility criteria to vet articles for full-text review. Twenty-nine studies remained for full-text review after our systematic review process was completed. Studies were subjected to several levels of analysis. First, pre-and post- test post-traumatic growth inventory (PTGI) scores were collected from all studies and analyzed through a forest plot using Hedges' g. Next, Montreal Neurological Institute (MNI) coordinates and t-scores were collected and analyzed using an Activation Likelihood Estimation (ALE) to measure brain function. T-scores and Hedges' g values were then analyzed using Pearson correlations to determine if there were any relationships between brain function and post-traumatic growth for each modality. Lastly, all studies were subjected to a bubble plot and Egger's test to assess risk of publication bias across the review sample.

Results

Forest plot results indicated that all three interventions had a robust effect on PTGI scores. ALE meta-analysis results indicated that EMDR exhibited the largest effect on brain function, with the R thalamus (t = 4.23, p < 0.001) showing robust activation, followed closely by the R precuneus (t = 4.19, p < 0.001). Pearson correlation results showed that EMDR demonstrated the strongest correlation between increased brain function and PTGI scores (r = 0.910, p < 0.001). Qualitative review of the bubble plot indicated no obvious traces of publication bias, which was corroborated by the results of the Egger's test (p = 0.127).

Discussion

Our systematic review and meta-analysis showed that CPT, EMDR, and PE each exhibited a robust effect on PTG impacts across the course of treatment. However, when looking closer at comparative analyses of neural activity (ALE) and PTGI scores (Pearson correlation), EMDR exhibited a more robust effect on PTG impacts and brain function than CPT and PE.

Fear in the mind's eye: the neural correlates of differential fear acquisition to imagined conditioned stimuli

Mental imagery is involved in both the expression and treatment of fear-related disorders such as anxiety and post-traumatic stress disorder. However, the neural correlates associated with the acquisition and generalization of differential fear conditioning to imagined conditioned stimuli are relatively unknown. In this study, healthy human participants (n = 27) acquired differential fear conditioning to imagined conditioned stimuli paired with a physical unconditioned stimulus (i.e. mild shock), as measured via self-reported fear, the skin conductance response and significant right anterior insula (aIn) activation. Multivoxel pattern analysis cross-classification also demonstrated that the pattern of activity in the right aIn during imagery acquisition was quantifiably similar to the pattern produced by standard visual acquisition. Additionally, mental imagery was associated with significant differential fear generalization. Fear conditioning acquired to imagined stimuli generalized to viewing those same stimuli as measured with self-reported fear and right aIn activity, and likewise fear conditioning to visual stimuli was associated with significant generalized differential self-reported fear and right aIn activity when imagining those stimuli. Together, the study provides a novel understanding of the neural mechanisms associated with the acquisition of differential fear conditioning to imagined stimuli and that of the relationship between imagery and emotion more generally.

Imagery re-scripting for PTSD: session content and its relation to symptom improvement

Imagery rescripting (ImRs) is a therapy technique that, unlike traditional re-living techniques, focuses less on exposure and verbal challenging of cognitions and instead encourages patients to directly transform the intrusive imagery to change the depicted course of events in a more desired direction. However, a comprehensive account of how and in what circumstances ImRs brings about therapeutic change is required if treatment is to be optimised, and this is yet to be developed. The present study reports on the development of a coding scheme of ImRs psychotherapy elements identified in the literature as potential ImRs mechanisms. The codes were assessed in relation to short-term outcomes of 27 individuals undergoing ImRs for post-traumatic stress disorder. The timing of the change in the image, degree of activation of the new image and associated cognitive, emotional and physiological processes, self-guided rescripting, rescript believability, narrative coherence and cognitive and emotional shift were identified as being related to symptom change and so are potentially important factors for the re-scripting process.

Imagery Rescripting as a stand-alone treatment for posttraumatic stress disorder related to childhood abuse: A randomized controlled trial

BACKGROUND AND OBJECTIVES

Posttraumatic stress disorder (PTSD) related to childhood abuse (CA) is associated with high symptom complexity. This study examined the efficacy of Imagery Rescripting (ImRs) as a stand-alone treatment versus a sequenced approach with Skills training in Affective and Interpersonal Regulation (STAIR) followed by ImRs for CA-related PTSD.

METHODS

Outpatients of two mental health clinics with CA-related PTSD (N = 61) were randomly assigned to ImRs (16 sessions; n = 21), STAIR/ImRs (8 STAIR-sessions followed by 16 ImRs-sessions; n = 20), or Waitlist (8 weeks; n = 20). Patients of the waitlist condition were also randomized to the two active conditions for comparison of STAIR/ImRs (total n for this condition = 31) and ImRs (total n for this condition = 30) and started treatment after waitlist completion. Assessments took place at pre-treatment, after each treatment phase and at 12-week post-intervention follow-up. PTSD symptoms and diagnosis were primary outcome measures, and depression, emotion regulation and interpersonal functioning were secondary outcomes.

RESULTS

ImRs showed greater reduction of PTSD severity (effect sizes [ES] 1.40-1.63) than STAIR (ES, 0.23-0.33) as compared to waitlist. When comparing STAIR/ImRs and ImRs directly, (i.e. including re-randomized Waitlist-patients), PTSD symptoms reduced significantly (within condition ES, 1.64-2.10) and improved further to 12-week follow-up (within-condition ES, 2.33-2.66), with no significant difference between both conditions (between-condition ES, 0.21-0.45). Loss of PTSD diagnosis was achieved by 70% in the ImRs condition and 86% in the STAIR/ImRs condition.

LIMITATIONS

The sample size was relatively small.

CONCLUSIONS

Results show that ImRs is an effective treatment for CA-related PTSD, whereby the current data do not convincingly show an additive effect of STAIR.

Perspectives of underweight people with eating disorders on receiving Imagery Rescripting trauma treatment: a qualitative study of their experiences

BACKGROUND

The prognosis for underweight individuals with an eating disorder (ED) and posttraumatic stress disorder (PTSD) is worse than for their peers without these comorbid symptoms. This qualitative study explores the experiences of trauma-focused Imagery Rescripting (ImRs) therapy of underweight inpatients being treated for an ED.

OBJECTIVE

To test the feasibility and to improve ImRs by understanding the experiences and perspectives of people with an ED and PTSD who, when underweight, received ImRs as an adjunct to their inpatient ED treatment.

METHOD

To explore how underweight people with an ED experience and perceive ImRs, we used a qualitative study design involving semi-structured interviews with 12 participants. After analysis, the data were summarized and classified within a thematic framework that focused on experiences and improving the ImRs method.

RESULTS

The thematic analysis resulted in the following 6 main themes; (1) Expectations of ImRs; (2) Ability to participate in ImRs; (3) Effect of ImRs; (4) Experience of ImRs technique; (5) Conditions under which ImRs is given; (6) In depth-analysis. The results show that despite the fear of disappointment the participants appreciate addressing the PTSD and ED symptoms simultaneously. Further, results showed that it had been possible for them to attend ImRs but that the effects of ImRs were not uniformly perceived. Also, participants indicated that a caring context is important and that ImRs should not be scheduled immediately before a meal. Finally, the treatment generated hope.

CONCLUSIONS

The findings of this study demonstrated the feasibility of the integration of ImRs trauma treatment for individuals who are being treated in an ED inpatient treatment setting, and are in contrast to standard practice where the focus of inpatient treatment has been ED-symptom improvement without comprehensively addressing past traumatic experiences during an underweight phase. Trial registration International Clinical Trials Registry Platform (ICTRP) (NTR6094). Date of registration 09/23/2016. https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6094.

Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review

INTRODUCTION

Individuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood.

METHODS

This review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates.

RESULTS

15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger.

CONCLUSIONS

The findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.

Blended delivery of imagery rescripting for childhood PTSD: A case study during the COVID-19 pandemic

Background

Despite the growing evidence that trauma-focused treatments can be applied as first-line approaches for individuals with childhood trauma-related PTSD (Ch-PTSD), many therapists are still reluctant to provide trauma-focused treatments as a first-choice intervention for individuals with Ch-PTSD, especially by telehealth. The current manuscript will therefore give an overview of the evidence for the effectiveness of trauma-focused therapies for individuals with Ch-PTSD, the delivery of trauma-focused treatments via telehealth, and a case example on how a specific form of trauma focused therapy: Imagery Rescripting (ImRs) can be applied by telehealth.

Method

This article presents a clinical illustration of a blended telehealth trajectory of imagery rescripting (ImRs) Ch-PTSD delivered during the COVID-19 pandemic.

Results

The presented case shows that ImRs can be safely and effectively performed by telehealth for ch-PTSD, no stabilization phase was needed and only seven sessions were needed to drastically reduce Ch-PTSD and depressive symptoms, and to increase quality of life.

Conclusion

This case report shows the effectiveness of ImRs by telehealth for Ch-PTSD, which gives hope and additional possibilities to reach out to patients with ch-PTDS. Telehealth treatment might have some of advantages for specific patients, especially, but certainly not only, during the pandemic.

An Investigation of Cognitive and Affective Changes During Group Imagery Rescripting for Social Anxiety Disorder

Recurrent, negative self-imagery is common in social anxiety disorder (SAD). Imagery rescripting (ImRs) is an effective therapeutic technique that aims to target past aversive memories to modify their associated meanings, and update the encapsulated negative schematic beliefs. The current study aimed to extend previous research by investigating the cognitive and affective shifts during each phase of ImRs delivered within a group cognitive behavioral therapy protocol. Participants (N = 32) retrieved an aversive memory associated with social anxiety and were guided through brief cognitive restructuring, prior to completing ImRs. Core beliefs associated with the memory (strength and valence) and fear of negative evaluation were assessed before and after ImRs and affect was assessed following each phase. Strength and affective valence of encapsulated core beliefs about the self, others, the world, and the image itself significantly reduced following ImRs, and core beliefs were updated to become more positive. Participants reported large affective shifts early in the process, with smaller shifts in the later stages. Fear of negative evaluation did not significantly reduce following ImRs. Outcomes provide some support for cognitive and affective changes during group ImRs for SAD and suggest future research directions to investigate longer-term impacts and to better understand the underlying mechanisms of the technique.

Fear in the Theater of the Mind: Differential Fear Conditioning With Imagined Stimuli

Many symptoms of anxiety and posttraumatic stress disorder are elicited by fearful mental imagery. Yet little is known about how visual imagery of conditioned stimuli (CSs) affects the acquisition of differential fear conditioning. Across three experiments with younger human adults (Experiment 1: n = 33, Experiment 2: n = 27, Experiment 3: n = 26), we observed that participants acquired differential fear conditioning to both viewed and imagined percepts serving as the CSs, as measured via self-reported fear and skin conductance responses. Additionally, this differential conditioning generalized across CS-percept modalities such that differential conditioning acquired in response to visual percepts generalized to the corresponding imagined percepts and vice versa. This is novel evidence that perceived and imagined stimuli engage learning processes in very similar ways and is consistent with the theory that mental imagery is depictive and recruits neural resources shared with visual perception. Our findings also provide new insight into the mechanisms of anxiety and related disorders.

A randomised multiple baseline case series of a novel imagery rescripting protocol for intrusive trauma memories in people with psychosis

BACKGROUND AND OBJECTIVES

There has been limited investigation of therapies targeting trauma-related psychological mechanisms hypothesised to play a role in post-traumatic and psychosis symptoms. Imagery rescripting (ImRs) is a therapeutic technique which involves transforming images, such as episodic memories, to modify associated distressing beliefs. This study is the first ImRs study for psychosis to incorporate experimental controls. We used a novel ImRs protocol, targeting present-focused, self-referential distressing meanings associated with intrusive trauma memories. A multiple baseline case series design investigated whether the protocol was feasible, safe, acceptable and effective.

METHODS

12 participants with a psychosis diagnosis and intrusive trauma memories were assessed and randomised to a monitoring period (one, two or three weeks), followed by three ImRs sessions (over three weeks), a further two-week monitoring period with a post-therapy assessment a week after completing therapy. Memory phenomenology was assessed daily during monitoring. Post-traumatic stress symptoms and wellbeing were assessed pre and post therapy.

RESULTS

ImRs was feasible, safe and rated as highly acceptable. No participants dropped-out of the brief, targeted intervention. There were moderate effects on the frequency, distress, controllability and appraisals of trauma memories. Notably, ten participants showed reliable change, and seven clinically significant change, in post-traumatic stress symptoms.

LIMITATIONS

Assessments were not blinded and impact on psychosis was not examined.

CONCLUSIONS

The study indicates that a brief, novel ImRs protocol targeting present-focused, self-referential meanings is a promising intervention for intrusive trauma memories. Future research should investigate its integration into trauma-focused therapy for psychosis and impact on psychosis severity.

Is it magic? An exploratory randomized controlled trial comparing imagery rescripting and cognitive restructuring in the treatment of depression

BACKGROUND AND OBJECTIVES

To investigate whether working with intrusive images and the use of imagery processes would be beneficial to treating depression, an imagery-based intervention (imagery rescripting, IR) was compared with a more commonly used verbal-based technique (cognitive restructuring, CR). The study aimed not only to test the efficacy of IR as a brief modular treatment for depression, but to explore whether such experiential use of imagery would alleviate the abstract-evaluative, verbal processes of rumination and worry.

METHODS

Forty-one participants diagnosed with clinical depression and who also reported intrusive images underwent one assessment session of imagery properties before they were randomly assigned to an IR group or to an active control group of CR. They then received three weekly sessions of treatment, and outcomes were measured before and after treatment, as well as at two-month follow-up.

RESULTS

The results showed that IR was equally if not more effective than CR in alleviating depression. Significant differential reductions in rumination, worry and experiential avoidance between treatments added support to the technique's experiential nature, and possibly, a defusing out of an abstract-evaluative mode of processing.

LIMITATIONS

Only self-report measures were used, with a small number of treatment sessions by one clinician.

CONCLUSIONS

The findings support the therapeutic potential of imagery modalities in the treatment of depression, which compared to cognitive restructuring, appear to bring about more significant emotional change with time (clinical trial registered at the Joint CUHK-NTEC CREC Ref. No. 2015.458).

Sleep's role in updating aversive autobiographical memories

Aversive autobiographical memories play a key role in the development and maintenance of many mental disorders. Imagery rescripting is a well-established psychotherapeutic intervention aiming to create a more adaptive version of an aversive memory by modifying its interpretation. Sleep has been shown to support reconsolidation of updated neutral memories. Here, we investigated in healthy participants whether a 90-min nap compared to wake supports the adaptive reconsolidation of autobiographical memories. Forty-four university students received a single 50-min imagery rescripting session. Thereafter, half of the participants took a 90-min nap, whereas the other half stayed awake. Subjective (arousal ratings, reports of emotions and dysfunctional cognitions) and heart rate (HR) responses to individual memory scripts were measured before the intervention (pre), after the 90-min retention interval (post 1) and 7 days later (post 2). Results demonstrate a significant decrease in distress of aversive memories pre to post imagery rescripting. The nap group showed less distressing dysfunctional cognitions along with a lower HR in response to the negative memory script as compared to the wake group at post 1. These differences were no longer evident 1 week later (post 2). Central sleep spindle density during the nap was correlated with the reduction in HR in response to the negative memory script from pre to post 1. Our results provide first evidence for sleep benefitting adaptive reconsolidation of aversive autobiographical memories. Future research should expand this approach to clinical populations and investigate precise conditions under which sleep may benefit psychotherapeutic interventions utilizing reconsolidation mechanisms.

Treating PTSD with Imagery Rescripting in underweight eating disorder patients: a multiple baseline case series study

BACKGROUND

Eating disorder patients with posttraumatic stress disorder have worse treatment results regarding their eating disorder than patients without posttraumatic stress disorder. Many eating disorder patients with co-morbid posttraumatic stress disorder symptoms are not treated for posttraumatic stress disorder symptoms during an underweight state. We propose that treatment of posttraumatic stress disorder is possible for underweight patients and that their trauma symptoms decrease with the use of Imagery Rescripting. We also investigated whether treatment of trauma influences eating disorder pathology in general and the process of weight gain specifically.

METHOD

Ten patients in clinical treatment (BMI 14-16.5) participated. A multiple baseline design was used, with baseline varying from 6 to 10 weeks, a 6-week treatment phase, a 3-week follow-up period and a 3-month follow-up measurement. Data were analysed with mixed regression.

RESULTS

Evidence was found that Imagery Rescripting had strong positive effects on posttraumatic stress disorder symptoms without interfering with eating disorder treatment. Positive effects were also found on a range of secondary emotional and cognitive measures.

CONCLUSION

Imagery Rescripting of traumatic memories is a possible and safe intervention for underweight eating disorder patients. It also had positive clinical effects. Trial registration Netherlands trial register (NTR) Trial NL5906 (NTR6094). Date of registration 09/23/2016. https://www.trialregister.nl/trial/5906 .

Internet-based imagery rescripting intervention for adult survivors of institutional childhood abuse in the former German Democratic Republic - a pilot study

Background: From 1949 to 1990, about 500,000 children and adolescents in the former German Democratic Republic (GDR) were placed in institutional care. Many of these individuals experienced physical and sexual abuse as well as general maltreatment. While this population group is in great need of psychosocial support, few low-threshold interventions aimed at the needs of adult survivors of institutional childhood abuse exist. Objective: This pilot study examines the efficacy of an internet-based imagery rescripting intervention in reducing psychopathological symptoms, within a population of survivors of institutional abuse from state childcare institutions, in the former GDR. Additionally, a case study is presented, depicting the treatment of a woman suffering from PTSD after having been institutionalised in the former GDR. Method: Participants received 10 internet-based writing assignments, based on the principles of imagery rescripting, specifically tailored to the needs of survivors of institutional childhood abuse in the GDR. The participants received personalised feedback on their assignments. Symptoms of posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), depression, and anxiety were assessed at pre- and post-treatment. Results: A total of 15 participants completed the intervention (mean age 56.2 years; 66.7% female). Paired t-tests showed a significant reduction of PTSD, CPTSD, depression, and anxiety symptoms. Large effect sizes were found for PTSD (d = 1.26), CPTSD (d = .97), depression (d = 1.08) and anxiety (d = 1.20). Conclusion: The results of this pilot study provide preliminary evidence for the efficacy and feasibility of the intervention in treating psychopathological symptoms in survivors of institutional abuse in the GDR. The case study additionally demonstrates the applicability of the intervention. A randomised controlled trial should be applied to further evaluate the intervention and its effects. Trial registration: German Clinical Trials Register identifier: DRKS00020266..

The application of imagery rescripting to intrusive autobiographical memories in depression

Intrusive autobiographical memories are a prominent feature of depression implicated in the onset and course of the disorder. Current cognitive behavioural treatment of depression does not specify techniques to address intrusive memories. Imagery rescripting has been demonstrated to be effective in the treatment of trauma-related intrusive memories. This paper illustrates the application of imagery rescripting as a stand-alone treatment for two patients experiencing a current major depressive episode. The two cases are described in detail and follow-up data are reported. Both patients experienced clinically significant and reliable change in their depression scores and no longer met criteria for a current major depressive episode at post-assessment, with gains maintained at 3-month follow-up. Implications are discussed for the theoretical mechanisms of change of this intervention as well as methods to overcome common treatment obstacles that arise in depression.

Key learning aims

(1)

Group Imagery Rescripting on Childhood Memories Delivered via Telehealth: A Preliminary Study

BACKGROUND

Imagery Rescripting (ImR) has proved to be effective in the treatment of different mental disorders as an integral part of broader clinical protocols or as a standalone technique. ImR has also been successfully incorporated as part of group Schema Therapy treatment; however, to the best of our knowledge, it has never been assessed as a standalone technique in a group setting.

AIM

In this study, we focused on ImR delivered via telehealth in groups and we aimed to assess whether group ImR is effective in responding to basic emotional needs, in changing participants' affective state, and in reducing dysfunctional beliefs. We also wanted to assess whether memory realism is associated with a greater effectiveness of the technique.

METHODS

A total of 52 participants were presented with 3 ImR sessions on childhood memories related to the current dysfunctional belief that elicited more suffering.

RESULTS

The technique was effective in facilitating the retrieval of a memory in almost the entire sample (in the range of 92.3-100%). Overall, memory realism values (level of vividness, ability to immerse, and participants' distance from the images) were high in all three sessions. Almost all participants were reported having their needs met during ImR (89.7%). Importantly, need satisfaction was associated with the ability to immerse in the image. In addition, the intensity of the dysfunctional belief decreased significantly from pre-test to Session 3. The technique also changed the affective state, reducing arousal. Importantly, we also observed a general reduction in shame levels from the first to the third session.

CONCLUSION

A telehealth delivered ImR group intervention on childhood memories provides cognitive and emotional improvement. Along with the ability to satisfy the patient's basic emotional needs, the technique seems to be effective in modifying maladaptive beliefs encapsulated in memory.

The effect of twice-weekly versus once-weekly sessions of either imagery rescripting or eye movement desensitization and reprocessing for adults with PTSD from childhood trauma (IREM-Freq): a study protocol for an international randomized clinical trial

Background

Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study’s aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated.

Methods

The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains.

Discussion

This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome.

Trial registration

Netherlands Trial Register NL6965, registered 25/04/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05712-9.

Clients' Emotional Experiences Tied to Therapist-Led (but Not Client-Led) Physiological Synchrony during Imagery Rescripting

Imagery rescripting (IR), an effective intervention technique, may achieve its benefits through various change mechanisms. Previous work has indicated that client–therapist physiological synchrony during IR may serve as one such mechanism. The present work explores the possibility that therapist-led vs. client-led synchrony may be differentially tied to clients’ emotional experiences in therapy. The analyses were conducted with data taken from an open trial of a brief protocol for treating test anxiety (86 IR sessions from 50 client–therapist dyads). Physiological synchrony in electrodermal activity was indexed using two cross-correlation functions per session: once for client leading and again for therapist leading (in both cases, with lags up to 10 s). The clients’ and therapists’ in-session emotions were assessed with the Profile of Mood States. Actor–partner interdependence models showed that certain client (but not therapist) in-session emotions, namely higher contentment and lower anxiety and depression, were tied to therapist-led (but not client-led) physiological synchrony. The results suggest that therapist-led synchrony (i.e., clients’ arousal tracking therapists’ earlier arousal) is tied to more positive and less negative emotional experiences for clients.

A cognitive behavioural therapy (CBT) approach for working with strong feelings of guilt after traumatic events

This article outlines a cognitive behavioural therapy (CBT) approach to treating feelings of guilt and aims to be a practical ‘how to’ guide for therapists. The therapeutic techniques were developed in the context of working with clients with a diagnosis of post-traumatic stress disorder (PTSD); however, the ideas can also be used when working with clients who do not meet a diagnosis of PTSD but have experienced trauma or adversity and feel guilty. The techniques in this article are therefore widely applicable: to veterans, refugees, survivors of abuse, the bereaved, and healthcare professionals affected by COVID-19, amongst others. We consider how to assess and formulate feelings of guilt and suggest multiple cognitive and imagery strategies which can be used to reduce feelings of guilt. When working with clients with a diagnosis of PTSD, it is important to establish whether the guilt was first experienced during the traumatic event (peri-traumatically) or after the traumatic event (post-traumatically). If the guilt is peri-traumatic, following cognitive work, this new information may then need to be integrated into the traumatic memory during reliving.

Key learning aims

(1)

Treating posttraumatic stress disorder in substance use disorder patients with co-occurring posttraumatic stress disorder: study protocol for a randomized controlled trial to compare the effectiveness of different types and timings of treatment

BACKGROUND

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have high comorbidity. Although prior research indicated that PTSD can effectively be treated with Prolonged Exposure (PE) in these patients, reported effects are small and treatment dropout rates high. Eye Movement Desensitization and Reprocessing (EMDR) and Imagery Rescripting (ImRs) are other promising treatment options for PTSD, that have not yet been examined in this patient group. Furthermore, it is unclear whether PTSD treatment is most effective when offered simultaneous to or after SUD treatment.

METHODS

In this article, the Treatment Of PTSD and Addiction (TOPA) study is described: a Dutch randomized controlled trial (RCT) that studies the effectiveness of PTSD treatment as an add-on to regular SUD treatment in patients with SUD and co-occurring PTSD. Effects of PE, EMDR, ImRs, and a 3-month SUD treatment only condition will be compared, as well as simultaneous SUD/PTSD treatment to sequential SUD/PTSD treatment. The primary outcome measure is PTSD symptoms. Secondary outcomes are: treatment completion, psychological distress, substance use, interpersonal problems, emotion dysregulation, and trauma-related emotions guilt, shame, and anger.

DISCUSSION

This study is the first to compare effects of PE, EMDR, and ImRs in one study and to compare simultaneous SUD/PTSD treatment to sequential SUD/PTSD treatment as well. This RCT will provide more knowledge about the effectiveness of different treatment strategies for PTSD in patients with co-occurring SUD and will ultimately improve treatment outcomes for patients with this common co-morbidity worldwide.

TRIAL REGISTRATION

Netherlands Trial Register (NTR), Identifier: NL7885 . Registered 22 July 2019.

The relationship between guilt, depression, prolonged grief, and posttraumatic stress symptoms after suicide bereavement

OBJECTIVE

A profound feeling of guilt and its role in complicating psychological reactions are accepted as central issues in suicide bereavement. However, research examining the relationship of guilt with mental disorders commonly following suicide bereavement is still lacking. This study aimed to examine the association between guilt and symptoms of depression, prolonged grief disorder, and posttraumatic stress disorder (PTSD) after suicide bereavement, as well as its moderating role in the association between the time which elapsed since bereavement and psychopathological symptoms.

METHODS

154 self-selected adult German participants bereaved by suicide completed online questionnaires assessing sociodemographics, characteristics related to the loss, guilt, depression, prolonged grief, and PTSD.

RESULTS

Significant positive correlations were found between guilt and all assessed psychopathological symptoms. Further, guilt was a significant correlate with symptoms of depression, prolonged grief, PTSD over and above sociodemographic factors, and time that elapsed since the loss. Guilt furthermore moderated the link between the time which elapsed since bereavement and depressive symptoms, while this effect was not observed for prolonged grief and posttraumatic stress symptoms.

CONCLUSION

Our findings replicate theoretical frameworks linking feelings of guilt with mental disorders after suicide bereavement. Accordingly, they highlight the necessity to adapt psychotherapeutic interventions according to the specific needs of this population to maximize treatment effectiveness.

Optimizing exposure: Between-session mental rehearsal as an augmentation strategy

Exposure therapy is widely empirically supported as a treatment for anxiety disorders, but clinically significant response rates hover around 50%. This study explores strategies for consolidating the exposure memory as a way of improving efficacy. Between-session mental rehearsal of exposure learning was examined as a way of enhancing the effects of exposure therapy. Sixty-two spider-fearful individuals completed baseline questionnaires and a behavioral approach test with a live tarantula, followed by two sessions of in vivo exposures, and a post-assessment one-week later that repeated the baseline questionnaires and behavioral approach test. Skin conductance, subjective distress, and number of steps completed were recorded at each behavioral approach test. Participants were randomized to mental rehearsal or control (non-specific) rehearsal that was prompted on three occasions after each exposure session. Participants in both conditions improved from baseline to post-assessment, but mental rehearsal participants showed significantly greater improvement than control participants across questionnaire measurements of spider fear, subjective distress, and number of steps completed during the behavioral approach test. Findings suggest that between-session mental rehearsal is an effective supplement to exposure therapy. As such, mental rehearsal may be a promising avenue toward increasing treatment response rates across many psychiatric disorders that benefit from exposure therapy.

Delivering Imagery Rescripting via Telehealth: Clinical Concerns, Benefits, and Recommendations

PURPOSE OF THE REVIEW

Delivery of psychological therapies via telehealth has increased with the emergence of the COVID-19 pandemic. Therapists may be hesitant in moving to telehealth when delivering therapies targeting memories of traumatic experiences. This paper collates the clinical experiences of clinicians and clients who have delivered or received imagery rescripting, respectively, via telehealth across a range of clinical presentations, and describes key clinical considerations and recommendations.

RECENT FINDINGS

It is important to consider perceived and real safety; practical and technological issues; therapeutic alliance; depth of emotional processing; and dissociation. There was support for the delivery of imagery rescripting via telehealth being no less effective than face-to-face delivery; however, telehealth delivery was not a viable option for many clients during COVID-19 lockdowns who were living in high density housing, old houses with thin walls, or with some complex disorders.

Improving imagery rescripting treatments: Comparing an active versus passive approach

BACKGROUND AND OBJECTIVES

In imagery rescripting (ImRs), aversive mental images are modified to reduce symptoms in a variety of psychological disorders. However, uniform guidelines on how to optimally implement ImRs do currently not exist. It remains unclear whether therapists should stimulate patients to imagine themselves to actively intervene within the new image, or whether they may imagine helpers to change the situation. We aimed to compare these two variants of ImRs within an analogue experimental setting.

METHODS

After having watched an aversive film, one-hundred participants were randomly assigned to active ImRs (ImRs-A), passive ImRs (ImRs-P), imagery rehearsal (IRE), or no-intervention control (NIC). Participants were either instructed to rescript the film by imagining themselves intervening in the new script (ImRs-A) or encouraged to imagine helpers to intervene in the imagined situation (ImRs-P).

RESULTS

Both ImRs increased mastery and elicited less distress than IRE with ImRs-P being experienced as less distressing than ImRs-A. Only ImRs-A led to a stronger increase in positive affect than IRE, whereas groups did not differ with respect to negative affect and self-efficacy. Conditions did not differ regarding the number of film-related intrusive memories.

LIMITATIONS

As a convenience sample was investigated, results cannot be generalized to clinical samples.

CONCLUSION

Even though differences regarding symptomatic outcome could not be detected, ImRs-P was experienced as less distressing than ImRs-A. Results suggest that both ImRs lead to different processes during the intervention than mere exposure. Compared to IRE, ImRs increases mastery with ImRs-A and ImRs-P being equally effective.

The role of simulation in imagery rescripting for post-traumatic stress disorder: a single case series

BACKGROUND

Imagery rescripting (ImRs) is an experiential therapy technique used to change the content and meaning of intrusive imagery in post-traumatic stress disorder (PTSD) by imagining alternative endings to traumatic events. There is growing evidence that ImRs is an effective treatment for PTSD; however, little is known about how it brings about change.

AIMS

This study aimed to explore the role of mental simulation as a candidate mechanism of action in ImRs, and, specifically, whether well-simulated imagery rescripts are associated with greater change in symptom severity during ImRs.

METHOD

Using a single-case experimental design, seven participants receiving cognitive therapy for PTSD were assessed before, during and after sessions of imagery rescripting for one intrusive image. Participants completed continuous symptom severity measures. Sessions were recorded, then coded for goodness of simulation (GOS) as well as additional factors (e.g. rescript believability, vividness).

RESULTS

Participants were divided into high- and low-responders and coding was compared across groups. Correlational analyses were supported by descriptive analysis of individual sessions. High-responders' rescripts tended to be rated as well-simulated compared with those of low-responders. Specific factors (e.g. intensity of thoughts/emotions related to original and new imagery elements, level of cognitive and emotional shift and belief in the resultant rescript) were also associated with reductions in symptom severity.

CONCLUSIONS

There was tentative evidence that well-simulated rescripted images tended to be associated with greater reductions in symptom severity of the target image. Clinical implications and avenues for further research are discussed.

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Rescripting experimental trauma: Effects of imagery and writing as a way to reduce the development of intrusive memories

BACKGROUND AND OBJECTIVES

Imagery rescripting is an effective treatment strategy for trauma related disorders, but its underlying mechanisms are still largely unknown. The aim of the present study was to test whether a) imagery (versus writing) is essential in the process of rescripting, and b) rescripting affects emotional memories on an implicit level.

METHODS

Healthy participants were subjected to an experimental trauma ('trauma film'), and randomly allocated to four conditions: recall of film + Imagery Rescripting (ImRs), recall of film + Writing Rescripting (WRs), recall only (ImRE), or no recall + no manipulation (NM). Next, participants recorded intrusion frequency and distress during one week, after which they executed a visual interference task (VIT) including neutral and trauma film stills, to access implicit emotional memory.

RESULTS

Main findings were that ImRs and WRs resulted in fewer intrusions than NM, with no differences between both rescripting conditions. We did not find an effect on intrusion distress and the VIT.

LIMITATIONS

Stills in the VIT were distracted from all four film scenes, whereas rescripting was done on one scene only, possibly obscuring the effect. Also, an analogue sample was used, which may limit generalizability to clinical samples.

CONCLUSIONS

We replicated previous effects of ImRs on intrusion development. Furthermore, no superior effect of imagery as key modality for rescripting was found; writing seems a viable alternative. Measures for implicit emotional memory such as the VIT may have to be applied relatively soon after the experimental session (e.g., same day as the experimental session).