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Kehr T, Haeyen S. Drawing your way out: Imagery rehearsal based art therapy (IR-AT) for post-traumatic nightmares in borderline personality disorder. J Clin Psychol 2024; 80:1015-1030. [PMID: 38193630 DOI: 10.1002/jclp.23638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 01/10/2024]
Abstract
Posttraumatic nightmares (PTN) are a frequent symptom after a traumatic event and often play part in the psychopathology of patients with borderline personality disorder (BPD). Imagery rehearsal therapy (IRT) currently offers the best evidence for an effective treatment to reduce PTNs, although high drop-out rates are common. Art therapy in IRT may counteract this, by its indirect, nonverbal, and often playful approach that helps to break through avoidance. This case study focusses on the perception of a patient with BPD in an art therapy based IRT treatment for patients with PTNs. It tells the story of Aurelia, a 40-year-old woman who, within this treatment, processes traumatic contents of her childhood like physical and sexual violence, but also current interactional problems that manifest themselves in her nightmares. Following the IR-AT treatment for PTNs Aurelia noticed a reduction in her nightmares, was less afraid of them and felt calmer towards her trauma. She expressed herself in the art medium and by this developed more self-efficacy. Her process resulted in an integration of the trauma and a perceived decrease in borderline symptoms. Future research can build on this basis to further explore the mechanisms and effects of IR-AT for PTNs.
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Affiliation(s)
- Timea Kehr
- LVR, Psychosomatic Medicine and Psychotraumatology, Cologne, Germany
| | - Suzanne Haeyen
- Academy of Health and Vitality, Research Group Arts & Psychomor Therapies in Health Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- GGNet, Centre for Mental Health, Scelta, Expert Centre for Personality Disorders Apeldoorn, Warnsveld, The Netherlands
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Pruiksma KE, Taylor DJ, Mintz J, Nicholson KL, Rodgers M, Young-McCaughan S, Hall-Clark BN, Fina BA, Dondanville KA, Cobos B, Wardle-Pinkston S, Litz BT, Roache JD, Peterson AL. A pilot randomized controlled trial of cognitive behavioral treatment for trauma-related nightmares in active duty military personnel. J Clin Sleep Med 2019; 16:29-40. [PMID: 31957648 DOI: 10.5664/jcsm.8116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The aim of this study was to obtain preliminary data on the efficacy, credibility, and acceptability of Exposure, relaxation, and rescripting therapy for military service members and veterans (ERRT-M) in active duty military personnel with trauma-related nightmares. METHODS Forty participants were randomized to either 5 sessions of ERRT-M or 5 weeks of minimal contact control (MCC) followed by ERRT-M. Assessments were completed at baseline, posttreatment/postcontrol, and 1-month follow-up. RESULTS Differences between ERRT-M and control were generally medium in size for nightmare frequency (Cohen d = -0.53), nights with nightmares (d = -0.38), nightmare severity (d = -0.60), fear of sleep (d = -0.44), and symptoms of insomnia (d = -0.52), and depression (d = -0.51). In the 38 participants who received ERRT-M, there were statistically significant, medium-sized decreases in nightmare frequency (d = -0.52), nights with nightmares (d = -0.50), nightmare severity (d = -0.55), fear of sleep (d = -0.48), and symptoms of insomnia (d = -0.59), posttraumatic stress disorder (PTSD) (d = -0.58) and depression (d = -0.59) from baseline to 1-month follow-up. Participants generally endorsed medium to high ratings of treatment credibility and expectancy. The treatment dropout rate (17.5%) was comparable to rates observed for similar treatments in civilians. CONCLUSIONS ERRT-M produced medium effect-size reductions in nightmares and several secondary outcomes including PTSD, depression, and insomnia. Participants considered ERRT-M to be credible. An adequately powered randomized clinical trial is needed to confirm findings and to compare ERRT-M to an active treatment control. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: A Pilot Randomized Controlled Trial of Treatment for Trauma-Related Nightmares In Active Duty Military Personnel; Identifier: NCT02506595; URL: https://clinicaltrials.gov/ct2/show/NCT02506595.
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Affiliation(s)
- Kristi E Pruiksma
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Daniel J Taylor
- Department of Psychology, University of North Texas, Denton, Texas
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Karin L Nicholson
- Department of Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | - Matthew Rodgers
- Department of Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Brittany N Hall-Clark
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Brooke A Fina
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Briana Cobos
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas
| | | | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center VA Boston Healthcare System, Boston, Massachusetts.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts.,Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - John D Roache
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas.,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas
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Holmes EA, Blackwell SE, Burnett Heyes S, Renner F, Raes F. Mental Imagery in Depression: Phenomenology, Potential Mechanisms, and Treatment Implications. Annu Rev Clin Psychol 2016; 12:249-80. [PMID: 26772205 DOI: 10.1146/annurev-clinpsy-021815-092925] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Mental imagery is an experience like perception in the absence of a percept. It is a ubiquitous feature of human cognition, yet it has been relatively neglected in the etiology, maintenance, and treatment of depression. Imagery abnormalities in depression include an excess of intrusive negative mental imagery; impoverished positive imagery; bias for observer perspective imagery; and overgeneral memory, in which specific imagery is lacking. We consider the contribution of imagery dysfunctions to depressive psychopathology and implications for cognitive behavioral interventions. Treatment advances capitalizing on the representational format of imagery (as opposed to its content) are reviewed, including imagery rescripting, positive imagery generation, and memory specificity training. Consideration of mental imagery can contribute to clinical assessment and imagery-focused psychological therapeutic techniques and promote investigation of underlying mechanisms for treatment innovation. Research into mental imagery in depression is at an early stage. Work that bridges clinical psychology and neuroscience in the investigation of imagery-related mechanisms is recommended.
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Affiliation(s)
- Emily A Holmes
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge CB2 7EF, United Kingdom; , , .,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Simon E Blackwell
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge CB2 7EF, United Kingdom; , ,
| | - Stephanie Burnett Heyes
- School of Psychology, University of Birmingham, Birmingham, West Midlands B15 2TT, United Kingdom; .,Department of Experimental Psychology, University of Oxford, Oxford OX1 3UD, United Kingdom
| | - Fritz Renner
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge CB2 7EF, United Kingdom; , ,
| | - Filip Raes
- Faculty of Psychology and Educational Sciences, University of Leuven, 3000 Leuven, Belgium;
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Abstract
Automatic defense responses promote survival and appropriate action under threat. They have also been associated with the development of threat-related psychiatric syndromes. Targeting such automatic responses during threat may be useful in populations with frequent threat exposure. Here, two experiments explored whether mental imagery as a pre-trauma manipulation could influence fear bradycardia (a core characteristic of freezing) during subsequent analog trauma (affective picture viewing). Image-based interventions have proven successful in the treatment of threat-related disorders and are easily applicable. In Experiment 1, 43 healthy participants were randomly assigned to an imagery script condition. Participants executed a passive viewing task with blocks of neutral, pleasant, and unpleasant pictures after listening to an auditory script that was either related (with a positive or a negative outcome) or unrelated to the unpleasant pictures from the passive viewing task. Heart rate was assessed during script listening and during passive viewing. Imagining negative related scripts resulted in greater bradycardia (neutral-unpleasant contrast) than imagining positive scripts, especially unrelated. This effect was replicated in Experiment 2 (n = 51), again in the neutral-unpleasant contrast. An extra no-script condition showed that bradycardia was not induced by the negative-related script, but rather that a positive script attenuated bradycardia. These preliminary results might indicate reduced vigilance after unrelated positive events. Future research should replicate these findings using a larger sample. Either way, the findings show that highly automatic defense behavior can be influenced by relatively simple mental imagery manipulations.
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Affiliation(s)
- Muriel A Hagenaars
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University Nijmegen , Nijmegen , Netherlands ; Department of Clinical Psychology, Leiden University , Leiden , Netherlands ; Biological Science Division, Department of Psychiatry, University of Chicago , Chicago, IL , USA
| | - Rahele Mesbah
- Department of Clinical Psychology, Leiden University , Leiden , Netherlands ; Department of Depression, PsyQ Rijnmond , Rotterdam , Netherlands
| | - Henk Cremers
- Department of Clinical Psychology, Leiden University , Leiden , Netherlands ; Biological Science Division, Department of Psychiatry, University of Chicago , Chicago, IL , USA
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