Timing of imagery rescripting during schema therapy for borderline personality disorder: the LUCY trial

Background

Early childhood adversity plays an important role in the etiology of borderline personality disorder (BPD). Current evidence suggests that trauma treatment for patients with BPD can be performed safely and that early trauma treatment has a positive effect on the course of PD. However, there is a scarcity of RCTs comparing the effects of the timing of trauma treatment during schema therapy (ST) for BPD on BPD severity. Therefore, the LUCY trial investigates the effects of the timing of trauma treatment by comparing early trauma treatment using imagery rescripting (ImRs) on the course of BPD during ST to trauma treatment in the middle of the treatment course.

Methods

In this multicenter RCT, two conditions are compared among 73 individuals with BPD. The participants receive combined individual and group ST in both conditions. However, in condition (A), participants directly start ImRs in the individual sessions in months 2-4, and in condition (B), participants receive ST-as-Usual (STAU), in which ImRs is not allowed during months 2-4. The treatment follows ST treatment protocols, consists of a fixed combination of individual sessions and group sessions with a maximum of nine patients, and has a maximum duration of 25 months. The primary outcome is change in BPD severity, which is assessed using the Borderline Personality Disorder Severity Index-5 by independent raters blinded to the treatment. Secondary outcome measures include treatment retention, disconnection/rejection schemas, general functioning, posttraumatic stress disorder symptoms, general psychopathological complaints, quality of life, happiness, schemas, and schema modes. Multilevel analysis will be performed to analyze and compare changes in BPD severity between conditions and generalized linear mixed model analyses to test predictors and moderators.

Discussion

This study will increase the knowledge on whether trauma treatment early in therapy positively affects the course of BPD manifestations during ST. When the early application of ImRs leads to a faster decrease in BPD manifestations, the treatment of BPD patients might be shortened, leading to improved treatment outcomes and decreased healthcare expenses. Moreover, the planned sub-studies will expand our knowledge of how ST works and the factors that influence the outcome of treatment.

Voice hearers' explanations of trauma-related voices and processes of change throughout imagery rescripting: A qualitative exploration

OBJECTIVES

Post-traumatic stress is common among people who hear voices (auditory verbal hallucinations), many of whom hear trauma-related voices, whereby voice content is related to past trauma. Preliminary evidence suggests that imagery rescripting (ImRs) may more effectively reduce post-traumatic stress and voices compared to treatments that are based on existing models of PTSD or positive symptoms. No known studies have explored the potential maintaining factors of trauma-related voices in relation to ImRs. We aimed to uncover insights into the factors that maintain trauma-related voices and how ImRs may influence such factors by exploring voice hearers' explanations of voices and experiences of change throughout ImRs.

DESIGN

Thematic analytical methodology was used due to the study's critical epistemological framework.

METHODS

Semi-structured interviews explored relationships between trauma and voices, and experiences of change and stability throughout ImRs in a transdiagnostic sample (N = 10) who underwent 10-18 weekly ImRs sessions. Thematic analysis was used to develop themes.

RESULTS

Two themes captured explanations of voices, which suggested voices may have counterproductive protective functions. Three themes captured psychological experiences during ImRs, which reflected concepts such as freedom to experience emotions, and experiences of justice, closure and grieving. Three themes described the outcomes of ImRs, reflecting concepts such as increased confidence, coping, perceived safety and voices becoming less powerful.

CONCLUSIONS

Trauma-related voices may have underlying protective functions and ImRs may support emotional expression, adaptive trauma re-appraisals and improve self-worth and coping self-efficacy. These change processes may have clinical implications in ImRs and other treatments for trauma-affected voice hearers.

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.

Intraindividual variability and emotional change as predictors of sudden gains in imagery rescripting and EMDR for PTSD in adult survivors of childhood abuse

Sudden gains, defined as large and stable improvements in symptom severity during psychological treatment, have consistently been found to be associated with better outcomes across treatments and diagnoses. Yet, insights on coherent predictors of sudden gains and on emotional changes around sudden gains in post-traumatic stress disorder (PTSD) are lacking. We aimed at replicating a measure of intraindividual variability as a predictor for sudden gains and testing its independence from change during treatment. Furthermore, we expected changes in emotions of guilt, shame and disgust prior to sudden gains to predict sudden gains. Data from a pre-registered randomized controlled trial (RCT) of eye-movement desensitization and reprocessing (emdr) and Imagery Rescripting (ImRs) for PTSD in 155 adult survivors of childhood abuse were used. Intraindividual variability of PTSD symptoms in both treatments did not predict sudden gains status and was not independent of change during treatment. In the EMDR condition, levels of shame during treatment predicted sudden gains and shame decreased shortly before a sudden gain in both treatments. Reductions in all emotions during sudden gains were significantly higher for participants with sudden gains than for comparable intervals in non-sudden gainers. Our findings do not support the predictive validity of intraindividual variability for sudden gains. The decrease of guilt, shame and disgust during sudden gains warrants further research on their role as a mechanism of treatment change for PTSD.

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.

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.

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.

A Case for Translation From the Clinic to the Laboratory

Laboratory procedures have been used for decades as analogues for clinical processes with the goal of improving our understanding of psychological treatments for emotional disorders and identifying strategies to make treatments more effective. This research has often focused on translation from the laboratory to the clinic. Although this approach has notable successes, it has not been seamless. There are many examples of strategies that work in the laboratory that fail to lead to improved outcomes when applied clinically. One possible reason for this gap between experimental and clinical research is a failure to focus on translation from the clinic to the laboratory. Here, we discuss potential benefits of translation from the clinic to the laboratory and provide examples of how this might be implemented. We first consider two well-established laboratory analogues (extinction and cognitive reappraisal), identify critical aspects of the related clinical procedures (exposure and cognitive restructuring) that are missing from these analogues, and propose variations to better capture the clinical process. Second, we discuss two clinical procedures that have more recently been brought into the laboratory (eye-movement desensitization and reprocessing and imagery rescripting). We conclude by highlighting potential implications of this proposed shift in focus for translational research.

Imagery rescripting and negative self-imagery in social anxiety disorder: a systematic literature review

BACKGROUND

Imagery rescripting (IR) is an effective intervention for social anxiety disorder (SAD) that targets memories of distressing formative events linked to negative self-imagery (NSI). IR is thought to update unhelpful schema by addressing the needs of the younger self within the memory. An accumulating body of evidence indicates that by modifying NSI, IR can significantly affect distressing imagery, memory appraisal, and beliefs about the self.

AIMS

This systematic review aims to critically evaluate and synthesise literature investigating the existing research on the effects IR has on NSI in SAD.

METHOD

A systematic electronic search of Academic Search Complete, ProQuest, Medline, Scopus and PubMed was performed in February 2021 using pre-defined criteria. Ten studies met the inclusion criteria and were selected for review.

RESULTS

Analysis of the reviewed articles' findings identified three main themes: Changes to negative self-images, Memories linked to images and Encapsulated beliefs. IR was associated with significant decreases in image distress, image vividness, memory vividness, memory distress, and encapsulated beliefs. Although reductions were found with image frequency, they were non-significant. Interpretation of results is limited by the small number of studies.

CONCLUSIONS

IR appears to effectively alter images, memories and beliefs in SAD in as little as a single session. The findings indicate that IR could be utilised as a cost-effective intervention for SAD. However, additional studies and longer-term follow-ups are needed.

Schema Therapy for Patients with Bipolar Disorder: Theoretical Framework and Application

Bipolar disorder (BD) is a severe mood disorder characterized by episodes of depression and hypomania or mania. Despite its primarily biological roots, the onset and course of the disorder have also been related to psychosocial factors such as early adverse experiences and related maladaptive schemas. Several researchers proposed a schema therapeutic model to treat patients with BD. In this paper, we further develop the theoretical model and elaborate on seven elements that were found effective in the psychosocial interventions with individuals with BD: monitoring mood and early symptoms of relapse, recognizing and management of stressful situations and interpersonal conflicts, creating a relapse prevention plan, stabilizing the sleep/wake cycle and daily routine, encouraging the use of medication, and reducing self-stigma and substance use. Apart from that, we describe the elements of the schema work with patients who suffer from BD. Illustrative clinical cases accompany the theoretical framework. The research of the schema therapy with patients with severe mental illnesses has only recently started developing. The presented paper also aims to encourage further research in this area and highlight potentially beneficial research goals.

Experience of Managing Countertransference Through Self-Guided Imagery in Meditation Among Healthcare Professionals

INTRODUCTION

As a part of the therapeutic relationship, a significant, well-established predictor of outcomes in psychiatric healthcare, healthcare professionals' emotional reactions to patients may affect treatment outcomes.

AIM

The aim of our study was to explore and describe healthcare professionals' experiences with managing countertransference using skills from a training program on self-guided imagery in meditation (SIM).

METHOD

Following an exploratory descriptive design, we conducted qualitative interviews with 10 healthcare professionals who care for patients with mental illness and subjected the collected data to thematic content analysis.

RESULTS

Participants reported that SIM had helped them to manage countertransference and had prompted changes that we categorized into three themes: managing personal vulnerability, setting clearer boundaries, and practicing self-care.

CONCLUSION

The results suggest that by cultivating wellbeing and dealing with unresolved inner conflicts, SIM can help healthcare professionals to manage countertransference.

Nightmare Rescripting: Using Imagery Techniques to Treat Sleep Disturbances in Post-traumatic Stress Disorder

Besides affecting 8% of the general population, nightmares are one of the most frequent symptoms of traumatized individuals. This can be a significant factor in the treatment of post-traumatic disorders; indeed, several studies demonstrated its strong predictive and prognostic value. Sleep disorders, nightmares in particular, could be very distressing for individuals and need targeted interventions, especially if they are associated with a PTSD diagnosis. To date, the best technique for the treatment of traumatic sleep disturbances seems to be Imagery Rehearsal Therapy (IRT), an empirically supported method. Through a review of the literature on this matter, this article aims to outline the incidence and consequences of nightmares in PTSD, illustrate how IRT could prove useful in their treatment, and investigate its clinical applications.

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.

Schema chemistry: An interpersonal framework for making sense of intimate partner violence

This article aims to use Schema theory to illustrate how interpersonal dynamics and their consequences have implications for individuals engaged in intimate partner violence. Schema theory would suggest that an intimate relationship creates a context where there is an increased likelihood of early relational patterns being repeated on both parts. On occasion, faulty assumptions being made about the motivations of the perpetrator resulting from a need for power and control can prevent a more curious exploration of the difficulties arising. The chapter will outline a case example to illustrate how a couples trauma histories can help to understand the triggers which result in harm being caused. This in no way suggests that a victim is to blame for violence perpetrated against them, but exploration of the interpersonal context can provide greater insight into the reasons why violence and coercive control may manifest.

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.

usual care and treatment advice in refugees with posttraumatic stress disorder: study protocol for a multi-center randomized-controlled trial

Background: Many refugees have experienced multiple traumatic events in their country of origin and/or during flight. Trauma-related disorders such as posttraumatic stress disorder (PTSD) or complex PTSD (CPTSD) are prevalent in this population, which highlights the need for accessible and effective treatment. Imagery Rescripting (ImRs), an imagery-based treatment that does not use formal exposure and that has received growing interest as an innovative treatment for PTSD, appears to be a promising approach. Objective: This randomized-controlled trial aims to investigate the efficacy of ImRs for refugees compared to Usual Care and Treatment Advice (UC+TA) on (C)PTSD remission and reduction in other related symptoms. Method: Subjects are 90 refugees to Germany with a diagnosis of PTSD according to DSM-5. They will be randomly allocated to receive either UC+TA (n = 45) or 10 sessions of ImRs (n = 45). Assessments will be conducted at baseline, post-intervention, three-month follow-up, and 12-month follow-up. Primary outcome is the (C)PTSD remission rate. Secondary outcomes are severity of PTSD and CPTSD symptoms, psychiatric symptoms, dissociative symptoms, quality of sleep, and treatment satisfaction. Economic analyses will investigate health-related quality of life and costs. Additional measures will assess migration and stress-related factors, predictors of dropout, therapeutic alliance and session-by-session changes in trauma-related symptoms. Results and Conclusions: Emerging evidence suggests the suitability of ImRs in the treatment of refugees with PTSD. After positive evaluation, this short and culturally adaptable treatment can contribute to close the treatment gap for refugees in high-income countries such as Germany. Trial registration: German Clinical Trials Register under trial number DRKS00019876, registered prospectively on 28 April 2020.

Using Imagery Rescripting as an Early Intervention for Depression in Young People

Innovation is urgently needed for school-based early interventions for depression. Imagery rescripting for aversive memories has been shown to be a valuable therapeutic approach in adults. Yet it is rarely applied to young people or to depression. This is surprising given that intrusive images of aversive memories are implicated in the development and maintenance of depression. We review the literature and describe the co-development of an imagery rescripting protocol for young people (age 16-18) with high symptoms of depression. To contextualize and illustrate this approach, we identify three themes of negative images emerging from the 37 participants who completed imagery rescripting and provide a detailed case example for each theme. The identified themes are failure, interpersonal adversity, and family conflict or disruption. Given that there is some therapist concern about using imagery rescripting, we highlight any reported negative consequences of engaging in imagery rescripting. We propose that imagery rescripting is an acceptable and potentially effective tool for early intervention in depression, which is significantly underutilized in current practice.

Clinical Efficacy and Cost-Effectiveness of Imagery Rescripting Only Compared to Imagery Rescripting and Schema Therapy in Adult Patients With PTSD and Comorbid Cluster C Personality Disorder: Study Design of a Randomized Controlled Trial

Background: Posttraumatic stress disorder (PTSD) is a serious and relatively common mental disorder causing a high burden of suffering. Whereas evidence-based treatments are available, dropout and non-response rates remain high. PTSD and Cluster C personality disorders (avoidant, dependent or obsessive-compulsive personality disorder; CPD) are highly comorbid and there is evidence for suboptimal treatment effects in this subgroup of patients. An integrated PTSD and CPD treatment may be needed to increase treatment efficacy. However, no studies directly comparing the efficacy of regular PTSD treatment and treatment tailored to PTSD and comorbid CPD are available. Whether integrated treatment is more effective than treatment focused on PTSD alone is important, since (1) no evidence-based guideline for PTSD and comorbid CPD treatment exists, and (2) treatment approaches to CPD are costly and time consuming. Present study design describes a randomized controlled trial (RCT) directly comparing trauma focused treatment with integrated trauma focused and personality focused treatment. Methods: An RCT with two parallel groups design will be used to compare the clinical efficacy and cost-effectiveness of "standalone" imagery rescripting (n = 63) with integrated imagery rescripting and schema therapy (n = 63). This trial is part of a larger research project on PTSD and personality disorders. Predictors, mediators and outcome variables are measured at regular intervals over the course of 18 months. The main outcome is PTSD severity at 12 months. Additionally, machine-learning techniques will be used to predict treatment outcome using biopsychosocial variables. Discussion: This study protocol outlines the first RCT aimed at directly comparing the clinical efficacy and cost-effectiveness of imagery rescripting and integrated imagery rescripting and schema therapy for treatment seeking adult patients with PTSD and comorbid cluster C personality pathology. Additionally, biopsychosocial variables will be used to predict treatment outcome. As such, the trial adds to the development of an empirically informed and individualized treatment indication process. Clinical Trial registration: ClinicalTrials.gov, NCT03833531.

Online imagery rescripting among young women at risk of developing an eating disorder: A randomized controlled trial

OBJECTIVE

This study compared the effectiveness of two approaches to imagery rescripting (body versus general) among young women with an elevated risk of developing an eating disorder.

METHOD

University students (N = 130 females) were randomly assigned to one of the four conditions: body or general imagery rescripting, psychoeducation, control. After initial brief laboratory training delivered online, participants in the imagery rescripting conditions were asked to practice imagery rescripting for 5 min each day for a week. Primary (global eating psychopathology, eating disorder behaviors, and body image acceptance) and secondary outcomes (self-compassion, fear of self-compassion, and dysfunctional attitudes) were measured at baseline and one-week follow up.

RESULTS

Completer analyses showed both imagery rescripting conditions and psychoeducation had significant impact on global eating psychopathology and body acceptance (d = 0.60-0.78). Psychoeducation did not impact secondary variables, whereas body imagery rescripting improved self-compassion and fear of self-compassion (d = 0.61-0.80) and general imagery rescripting improved dysfunctional attitudes (d = 0.82) compared to control. Intent to treat analyses had similar but slightly less robust results.

DISCUSSION

While three active groups had significant impact on the primary variables, imagery rescripting approaches had impact on other variables that maintain disordered eating. Future research should investigate the impact of combining psychoeducation and imagery rescripting in terms of impact on disordered eating.

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.

Imagery rescripting and eye movement desensitisation and reprocessing as treatment for adults with post-traumatic stress disorder from childhood trauma: randomised clinical trial

BACKGROUND

Investigation of treatments that effectively treat adults with post-traumatic stress disorder from childhood experiences (Ch-PTSD) and are well tolerated by patients is needed to improve outcomes for this population.

AIMS

The purpose of this study was to compare the effectiveness of two trauma-focused treatments, imagery rescripting (ImRs) and eye movement desensitisation and reprocessing (EMDR), for treating Ch-PTSD.

METHOD

We conducted an international, multicentre, randomised clinical trial, recruiting adults with Ch-PTSD from childhood trauma before 16 years of age. Participants were randomised to treatment condition and assessed by blind raters at multiple time points. Participants received up to 12 90-min sessions of either ImRs or EMDR, biweekly.

RESULTS

A total of 155 participants were included in the final intent-to-treat analysis. Drop-out rates were low, at 7.7%. A generalised linear mixed model of repeated measures showed that observer-rated post-traumatic stress disorder (PTSD) symptoms significantly decreased for both ImRs (d = 1.72) and EMDR (d = 1.73) at the 8-week post-treatment assessment. Similar results were seen with secondary outcome measures and self-reported PTSD symptoms. There were no significant differences between the two treatments on any standardised measure at post-treatment and follow-up.

CONCLUSIONS

ImRs and EMDR treatments were found to be effective in treating PTSD symptoms arising from childhood trauma, and in reducing other symptoms such as depression, dissociation and trauma-related cognitions. The low drop-out rates suggest that the treatments were well tolerated by participants. The results from this study provide evidence for the use of trauma-focused treatments for Ch-PTSD.

Treatment of survivor guilt after trauma using imagery rescripting: a proof-of-concept study

Survivor guilt can arise after surviving a trauma in which others die. No studies have systematically investigated psychological treatment for survivor guilt. The present study was a proof-of-concept investigation of treatment of survivor guilt using imagery rescripting. Thirteen participants with post-traumatic stress disorder and self-reported survivor guilt attended two consecutive imagery therapy sessions, to first elaborate and then rescript related imagery. Significant improvements were observed on idiographic process measures of cognitons, emotions and distress related to survivor guilt following the rescripting session. The study provides preliminary evidence that imagery rescripting can be used as an experiential technique to treat survivor guilt.

Experiences of Patients With Borderline Personality Disorder With Imagery Rescripting in the Context of Schema Therapy-A Qualitative Study

Imagery Rescripting (IR) is a therapeutic technique that is used in a wide spectrum of therapeutic methods for various mental disorders. As an important component of Schema Therapy (ST), IR is frequently used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how IR is experienced by individuals with BPD. The aim of this study was to explore BPD patients' experiences with receiving IR. Qualitative data were collected through semi-structured interviews with 21 individuals (86% females) with a primary diagnosis of BPD who received IR within their ST treatment. Interview data were analyzed following the procedures of qualitative content analysis. Participants reported various effects of IR including initial high emotionality and exhaustion. Long-term effects included a better understanding of schemas and an improvement regarding emotion regulation and interpersonal relationships. Participants reported factors hindering the successful implementation of IR, such as external noise, stress, and a fast pace during IR. Facilitating factors included adequate time for debriefing, a transparent structure, and preparation of IR as well as the therapist providing safety. Implications of the findings for optimizing IR in clinical practice are discussed.

Short Imagery Rescripting Intervention to Treat Emotionally Dysregulated Behavior in Borderline Personality Disorder: An Exploratory Study

BACKGROUND

Current research on borderline personality disorder report an association between emotionally dysregulated behaviors and intrusive mental imagery depicting similar scenes. Imagery rescripting techniques have proven effective in reducing intrusive mental imagery in numerous contexts. We developed a two session-short intervention in which intrusive mental images are identified, analyzed, and modified for daily rehearsal at home. This study aimed to reduce the negative emotions and cognitions associated with self-injurious behaviors by replacing unhealthy imagery with more adaptive content.

METHODS

Seven females diagnosed with borderline personality disorder who reported intrusive mental imagery of dysregulated behaviors were recruited for participation. Each participant engaged in two individualized treatment sessions and daily homework requiring the rehearsal of modified imagery. Emotion regulation strategies, borderline symptom severity, and depressiveness were assessed before and after treatment.

RESULTS

Acceptance was positive, as no patient dropped out from treatment. Symptom exacerbation was not observed. Borderline symptom reduction was noted and indicia of emotional dysregulation and negative affect declined.

LIMITATIONS

The generalizability of results is limited by the small sample size and the absence of a control group. Conclusions: This new two-session short intervention was shown to decrease the emotionally dysregulated behaviors that accompany negative feelings in females with borderline personality disorder.

Imagery Rescripting: Exploratory Evaluation of a Short Intervention to Reduce Test Anxiety in University Students

BACKGROUND

Test anxiety is common in university students. Demanding schedules may contribute to the relatively low utilization of professional counseling, when compared to other anxiety disorders. A possible solution could be a psychotherapeutic short-term intervention. The present exploratory study implemented a short-term psychotherapeutic treatment, consisting of two imagery rescripting (IR) sessions. The efficacy of IR techniques has already been demonstrated in the treatment of various anxiety disorders including test anxiety.

METHODS

Nine students suffering from test anxiety (m = 3, f = 6) underwent two weekly applied sessions of IR. Outcome variables were examined one week prior to (t1), immediately after (t2) and three months after (t3) the intervention, using self-evaluation questionnaires on test anxiety (PAF), depressive symptoms (BDI II), life satisfaction (FLZ), general self-efficacy and study-specific self-efficacy (WIRKALL; WIRK_STUD), intrusiveness of mental images (IFES), and change and acceptance (VEV; ZUF; BFTB).

RESULTS

There were no dropouts. According to results from ZUF and BFTB, the participants where highly satisfied with the intervention. PAF scores decreased significantly over time (t1 to t3), whereas WIRKALL scores (t1 to t3) and WIRK_STUD scores (t1 to t3 and t2 to t3) increased significantly. IFES scores decreased immediately after the intervention (t1 compared to t2) and further after the follow-up (t1 to t3). No changes in BDI-II scores were observed.

DISCUSSION

The findings indicate a high acceptance and efficacy of the two-session IR-intervention. Limits are the lack of a control group, and the small sample size. Further evaluation in future controlled studies is needed.

Imagery Rescripting on Guilt-Inducing Memories in OCD: A Single Case Series Study

BACKGROUND AND OBJECTIVES

Criticism is thought to play an important role in obsessive-compulsive disorder (OCD), and obsessive behaviors have been considered as childhood strategies to avoid criticism. Often, patients with OCD report memories characterized by guilt-inducing reproaches. Starting from these assumptions, the aim of this study is to test whether intervening in memories of guilt-inducing reproaches can reduce current OCD symptoms. The emotional valence of painful memories may be modified through imagery rescripting (ImRs), an experiential technique that has shown promising results.

METHODS

After monitoring a baseline of symptoms, 18 OCD patients underwent three sessions of ImRs, followed by monitoring for up to 3 months. Indexes of OCD, depression, anxiety, disgust, and fear of guilt were collected.

RESULTS

Patients reported a significant decrease in OCD symptoms. The mean value on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) changed from 25.94 to 14.11. At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS. Thirteen patients reported a reliable improvement, with ten reporting a clinically significant change (reliable change index = 9.94). Four reached the asymptomatic criterion. Clinically significant changes were not detected for depression and anxiety.

CONCLUSIONS

Our findings suggest that after ImRs intervention focusing on patients' early experiences of guilt-inducing reproaches there were clinically significant changes in OCD symptomatology. The data support the role of ImRs in reducing OCD symptoms and the previous cognitive models of OCD, highlighting the role of guilt-related early life experiences in vulnerability to OCD.

Mediators of Change in Imagery Rescripting and Imaginal Exposure for Nightmares: Evidence From a Randomized Wait-List Controlled Trial

Imagery rescripting (IR) and imaginal exposure (IE) are two efficacious treatments for nightmare disorder, but their discrete underlying mechanism(s) remain largely unknown. We therefore examined mediators of the treatment effects of IR and IE in a randomized wait-list controlled trial (N = 104). Therapeutic outcomes were assessed at pre- and post-assessment, and mediator assessment took place in between treatment sessions to establish a temporal relationship between mediators and nightmare symptoms (i.e., frequency and distress). In line with the hypothesis, enhanced mastery (or self-efficacy) of the nightmare content mediated the therapeutic efficacy of IR. Furthermore, the treatment effects of IE were mediated by increased tolerability of the negative emotions elicited by nightmares. Even though IR and IE for nightmares seem to produce similar therapeutic effects, the results of this study suggest that IR and IE tap into different underlying processes.

Does Transcranial Direct Current Stimulation (tDCS) Improve Disgust Regulation Through Imagery Rescripting?

The first pilot studies have shown the potential of imagery rescripting (ImR) for reducing contamination-related pathological disgust, although the effects were rather small. The aim of the present study is to investigate whether the effects of ImR in reducing disgust can be further increased by transcranial direct current stimulation (tDCS). tDCS is a non-invasive method of brain stimulation that has been successfully used multiple times to support emotion-regulation strategies. In the present study, disgust was induced via images related to individualized sources of disgust. Fifty-eight healthy volunteers took part in two parallel experiments. The two groups were matched by age, highest educational level and gender, and were tested under two emotion-regulation conditions, namely an ImR condition and a control condition. Participants performed three trials on the first day and three trials on the second day. Across both days they performed three trials under each of the two emotion-regulation conditions in a randomized order. On one day active stimulation was applied, while on the other day participants were sham stimulated. The combination of emotion-regulation and stimulation condition was balanced across subjects. The only difference between the two groups was the localization of tDCS stimulation: one group was stimulated over the dorsolateral prefrontal cortex and the other group was stimulated over the visual cortex (VC). This experimental manipulation was implemented to gain further insights into the underlying neuropsychological mechanisms of imagery. ImR was conducted via a previously-recorded audio file. The results confirm the effect of ImR on the reduction of disgust. However, with the present experimental design we were not able to show that supplementary tDCS of the VC or the dorsolateral prefrontal cortex lead to improvement.

Imagery rescripting in individuals with binge-eating behavior: An experimental proof-of-concept study

OBJECTIVE

Mental imagery is more strongly related to emotions than verbal cognitions. Binge eating is associated with dysfunctional emotional regulation. However, cognitive therapy techniques have focused on verbal cognitions. This proof-of-concept study compares a traditional cognitive therapy technique, cognitive restructuring (CR), with imagery rescripting (IR) in individuals with binge-eating disorder or bulimia nervosa.

METHOD

Thirty-six participants were asked to recall an idiosyncratic mental image of social rejection. They were then randomly assigned to a single session of CR or IR. Ratings of positive and negative emotions, and impact on rational and emotional core beliefs were administered prior to and after imagery recall, after the experimental intervention, and 1 week later. Eating disorder psychopathology was measured before and 1 week after the experimental intervention.

RESULTS

Repeated measures ANOVAs revealed that after the experimental intervention, negative emotions and core beliefs had significantly decreased in CR and IR. Both groups also showed an increase in positive emotions that lasted until 1-week follow-up.

DISCUSSION

This study suggests that CR and IR as an experimental intervention have comparable impact on distress and rational and emotional core beliefs. The feasibility of IR has been demonstrated. The effect of imagery recall on CR needs further investigation.

Exploratory study of imagery rescripting without focusing on early traumatic memories for major depressive disorder

BACKGROUND

Mental imagery has a more powerful impact on our emotions than thinking in words about the same material. Treating intrusive images with imagery rescripting (IR) has been reported for various disorders, including post-traumatic stress disorder, social anxiety disorder, and bipolar disorder. There has been less research about IR as a major depressive disorder (MDD).

AIMS

We examined whether IR without focusing on early traumatic memories is effective in MDD.

METHODS

We enrolled 19 participants with MDD, who received 15 weekly sessions of full CBT, including two sessions for IR of intrusive images and, separately, for memory rescripting. Before and after the IR intervention, participants were asked to rate the intrusive images they experienced against, an intrusion index that included difficulty (interference with daily life), uncontrollability, distress caused by the negative image, and vividness. We recorded the contents of each participant's negative and positive imagery to classify these.

RESULTS

The intrusion index scores decreased after the IR sessions. Negative images experienced by the participants while in a depressive mood were categorized into three different types: blame, social exclusion, and loneliness. The rescripted positive images were categorized into good relations and worthy self (competent self).

CONCLUSIONS

These results suggest that IR of intrusive images without focusing on early traumatic memories may usefully be incorporated into routine CBT sessions for MDD.

Imagery rescripting and cognitive dissonance: A randomized controlled trial of two brief online interventions for women at risk of developing an eating disorder

OBJECTIVE

This pilot study compared two brief online interventions, imagery rescripting and cognitive dissonance, to an assessment-only control condition in a sample of body-dissatisfied young women at risk of developing an eating disorder. We examined the degree to which each intervention reduced disordered eating and modified risk and protective factors for eating disorders.

METHOD

Female university students (N = 107, 17-28 years of age) completed a screening questionnaire, followed by random allocation to one of the three conditions, followed by a baseline assessment, body dissatisfaction induction, and brief online intervention. Participants in the active conditions then completed online daily home practice and a postintervention questionnaire.

RESULTS

Findings provide qualified support for the imagery rescripting intervention, with participants reporting higher body image acceptance (Cohen's d = 0.49) than the cognitive dissonance condition, and higher self-compassion (d = 0.59) and lower levels of disordered eating (d = 0.59) than the control condition, at postintervention. There was no significant impact of cognitive dissonance on any factors. Change in body image acceptance and self-compassion mediated the relationship between allocated condition and change in disordered eating at postintervention.

DISCUSSION

These findings provide preliminary support for the use of online-adapted imagery-based techniques (e.g., imagery rescripting) to reduce risk for the development of an eating disorder by strengthening protective factors (i.e., body image acceptance and self-compassion) and reducing disordered eating. Further exploration of the use of imagery strategies in the prevention of disordered eating is required, including prospective tests of the mechanisms of action.

Rescripting Memory, Redefining the Self: A Meta-Emotional Perspective on the Hypothesized Mechanism(s) of Imagery Rescripting

Imagery Rescripting (ImRs) is a therapeutic technique that aims to reduce the distress associated with negative memories of early aversive experiences. It consists of prompting patients to rescript the autobiographical memory in line with their unmet needs. In recent years, ImRs was found effective in reducing symptoms of disorders such as depression, social phobia, obsessive-compulsive disorder, post-traumatic stress disorder, and personality disorders. However, the cognitive mechanisms underlying such broad effectiveness are currently an object of debate. Empirical evidence has shown that ImRs reduces the negative self-belief derived from aversive memories in different types of mental disorders. However, existing accounts are not very accurate in explaining how this change in self-belief occurs and therefore why ImRs is effective across psychopathologies. We propose that ImRs changes the semantic self-representation encapsulated in the aversive memory by reducing the meta-emotional problem (i.e., perceiving a negative emotion as problematic and unacceptable). Empirical evidence implicates the meta-emotional problem or “secondary problem” in the maintenance of different disorders and has shown that treating it leads to symptoms reduction. Here we hypothesize that: (i) ImRs as a stand-alone treatment may lead to a reduction of symptoms; negative self-belief and the meta-emotional problem; and (ii) the reduction of the meta-emotional problem might mediate the relation between symptoms and negative self-belief reduction. To test our hypothesis, we present an experimental procedure that could be used in future studies. We conclude discussing the existing theoretical frameworks that attempt to unravel the mechanisms that play a role in ImRs.

Is It Possible to Enhance Intensity in Guided Imagery Exercises? An Experimental Study

OBJECTIVE

Guided imagery exercises can have a powerful impact on distressing mental images. Clinically, it is usually recommended to experience these exercises as intensely as possible. However, patients sometimes object to the related instructions. In this study, we tested whether typical clinical instructions aiming at increasing intensity led to a stronger effect of the exercise.

METHODS

Sixty-four healthy participants watched a trauma movie clip. Then they were pseudo-randomized into one of two strategies (intense, less intense) or a waiting control condition. Dependent variables were self-reported emotional intensity and psychophysiology measures.

RESULTS

Participants in the intense ImRS strategy did not experience the exercise as more intense than those in the less intense ImRS strategy on any outcome measure. Both ImRS strategies showed increased sympathetic activation compared to a decrease of activation in the waiting control group.

CONCLUSIONS

Our results suggest that emotional intensity in guided imagery exercises may not depend very much on the therapist's instructions.

Guilt, Shame and Compassionate Imagery in War: Traumatized German Soldiers with PTSD, a Pilot Study

BACKGROUND

The consideration of specific trauma-associated emotions poses a challenge for the differential treatment planning in trauma therapy. Soldiers experiencing deployment-related posttraumatic stress disorder often struggle with emotions of guilt and shame as a central component of their PTSD.

OBJECTIVE

The purpose of this study was to examine the extent to which soldiers' PTSD symptoms and their trauma-related guilt and shame may be affected as a function of their ability to develop compassionate imagery between their CURRENT SELF (today) and their TRAUMATIZED SELF (back then).

METHOD

The sample comprised 24 male German soldiers diagnosed with PTSD who were examined on the Posttraumatic Diagnostic Scale (PDS) and two additional measures: the Emotional Distress Inventory (EIBE) and the Quality of Interaction between the CURRENT SELF and the TRAUMATIZED SELF (QUI-HD: Qualität der Interaktion zwischen HEUTIGEN ICH und DAMALIGEN ICH) at pre- and post-treatment and again at follow-up. The treatment used was imagery rescripting and reprocessing therapy (IRRT).

RESULTS

Eighteen of the 24 soldiers showed significant improvement in their PTSD symptoms at post-treatment and at follow-up (on their reliable change index). A significant change in trauma-associated guilt and shame emerged when compassionate imagery was developed towards one's TRAUMATIZED SELF. The degree and intensity of the guilt and shame felt at the beginning of treatment and the degree of compassionate imagery developed toward the TRAUMATIZED SELF were predictors for change on the PDS scores.

CONCLUSIONS

For soldiers suffering from specific war-related trauma involving PTSD, the use of self-nurturing, compassionate imagery that fosters reconciling with the traumatized part of the self can effectively diminish trauma-related symptoms, especially when guilt and shame are central emotions.

Imagery Rescripting for Body Dysmorphic Disorder: A Multiple-Baseline Single-Case Experimental Design

Individuals with body dysmorphic disorder (BDD) often experience negative distorted images of their appearance, and research suggests these may be linked to memories of adverse events such as bullying or teasing. This study evaluates imagery rescripting (ImR) as an intervention for BDD. In this article, we present a multiple-baseline single-case experimental design testing imagery rescripting as a brief, stand-alone intervention, with six individuals with BDD that related to aversive memories. The impact of the intervention was assessed by self-reported daily measures of symptom severity (preoccupation with appearance, appearance-related checking behaviors, appearance-related distress, and strength of belief that their main problem is their appearance) and standardized clinician ratings of BDD severity (Yale-Brown Obsessive Compulsive Scale modified for BDD). Four out of six of the participants responded positively to the intervention, with clinically meaningful improvement in symptomatology. Overall response was rapid; improvements began within the first week post-ImR intervention. From a small sample it is cautiously concluded that imagery rescripting may show promise as a module in cognitive-behavioral therapy for BDD, and is worthy of further investigation.

Experimental single-session imagery rescripting of distressing memories in bowel/bladder-control anxiety: a case series

Bowel and bladder obsession [bowel/bladder-control anxiety (BBCA)] is a viscerally centered phobic syndrome involving a specific concern about losing control of bowel or bladder functioning in a public place. Like other anxiety disorders, BBCA is characterized by intrusive imagery. We have previously described the nature of intrusive mental imagery in BBCA and found imagery themes to be linked to actual experiences of loss of control or to "near misses." A causal role for imagery in symptom maintenance can be inferred by examining the effects of imagery rescripting. Moreover, successful rescripting may point to a potentially efficacious avenue for treatment development. Three cases of imagery rescripting are described here with pre-, post-, and follow-up (1-week) data reported. After rescripting, two participants experienced pronounced reductions in imagery vividness, distress, shame, disgust, and belief conviction. Most importantly, all three participants experienced a reduction in fear-associated bladder and/or bowel sensations. The results support a causal role for mental imagery in bowel-bladder-control anxiety and suggest that rescripting of distressing intrusive memories linked to recurrent images may be a useful avenue for development of cognitive-behavioral treatments of bladder/bowel-control anxiety.

Accelerated Resolution Therapy for treatment of pain secondary to symptoms of combat-related posttraumatic stress disorder

BACKGROUND

As many as 70% of veterans with chronic pain treated within the US Veterans Administration (VA) system may have posttraumatic stress disorder (PTSD), and conversely, up to 80% of those with PTSD may have pain. We describe pain experienced by US service members and veterans with symptoms of PTSD, and report on the effect of Accelerated Resolution Therapy (ART), a new, brief exposure-based therapy, on acute pain reduction secondary to treatment of symptoms of PTSD.

METHODS

A randomized controlled trial of ART versus an attention control (AC) regimen was conducted among 45 US service members/veterans with symptoms of combat-related PTSD. Participants received a mean of 3.7 sessions of ART.

RESULTS

Mean age was 41.0 + 12.4 years and 20% were female. Most veterans (93%) reported pain. The majority (78%) used descriptive terms indicative of neuropathic pain, with 29% reporting symptoms of a concussion or feeling dazed. Mean pre-/post-change on the Pain Outcomes Questionnaire (POQ) was -16.9±16.6 in the ART group versus -0.7±14.2 in the AC group (p=0.0006). Among POQ subscales, treatment effects with ART were reported for pain intensity (effect size = 1.81, p=0.006), pain-related impairment in mobility (effect size = 0.69, p=0.01), and negative affect (effect size = 1.01, p=0.001).

CONCLUSIONS

Veterans with symptoms of combat-related PTSD have a high prevalence of significant pain, including neuropathic pain. Brief treatment of symptoms of combat-related PTSD among veterans by use of ART appears to acutely reduce concomitant pain.

Imagery Rescripting of Early Traumatic Memories in Social Phobia

Negative self-images appear to play a role in the maintenance of social phobia and research suggests they are often linked to earlier memories of socially traumatic events. Imagery rescripting is a clinical intervention that aims to update such unpleasant or traumatic memories, and is increasingly being incorporated in cognitive behavioral therapy programs. In previous research, we have found that imagery rescripting was superior to a control condition in terms of its beneficial effects on negative beliefs, image and memory distress, fear of negative evaluation, and anxiety in social situations. In this article, we describe our imagery rescripting procedure. We consider the importance of updating negative imagery in social phobia, the theoretical basis for imagery rescripting, directions for future research, and how to conduct imagery rescripting, including potential problems and their solutions.

When the present visits the past: updating traumatic memories in social phobia

Research suggests that distorted images of the self are common in social phobia and play a role in maintaining the disorder. The images are often linked in thematic and sensory detail to distressing memories that are clustered around the onset or worsening of the disorder. This has led to speculation about the likely benefit of working directly with these memories to improve symptoms of social phobia. In this exploratory study, we describe a process of cognitive restructuring followed by imagery rescripting to update the meanings of distressing memories and images in social phobia. We first present illustrative clinical examples and then data of 14 patients with social phobia, on whom we developed this approach. Patients attended an imagery rescripting session in which a semi-structured interview was used to identify their recurrent images, the associated memories and their meanings. Next the identified memory was evoked and elaborated. We updated the meaning of the memory by first using cognitive restructuring to arrive at new perspectives and then linking these perspectives with the memory using imagery techniques. The procedure resulted in significant within session change in beliefs, and in image and memory distress and vividness. One week later significant change was seen in social phobia cognitions and a self-report measure of social anxiety. Rescripting distressing memories in social phobia appears to be an effective way of modifying maladaptive beliefs linked to recurrent negative imagery. This paper presents our exploratory investigation of how to work with the memories and encourages more rigorous investigation in this area.