Imagery Rescripting as
Treatment for Depressive Disorder,
Anxiety Disorders and
Post-Traumatic Stress Disorder
Bosgra, Jelte
University of Amsterdam
2014
ABSTRACT Imagery rescripting is a rarely described therapy that is used within Cognitive Behavioral Therapy (CBT) as well as other therapeutic approaches. Its effectiveness is expected by its users and is examined in this thesis through review of various studies. Hereby imagery rescripting is applied as a combined treatment with exposure or as a standalone treatment. Negative cognitions and intrusive images are amenable to change through rescripting therapy. Imagery rescripting affects these symptoms and has influence on emotions that tend to be less susceptible to usual treatment, like anger and guilt. Imagery rescripting seems to be a successful technique with promising results in the treatment of various disorders, especially in the treatment of posttraumatic stress disorder (PTSD). However, further research is required to confirm the stated hypotheses in the articles below.
Imagery rescripting as a combined or standalone treatment to reduce symptoms of depressive disorder, anxiety disorders and posttraumatic stress disorder. The use of imagery rescripting is not unknown as a therapy, as it has been used for a long time. The technique was clearly described in the late 19th century, after which it was ignored by a great part of the Freudian and postFreudian psychoanalytic followers (Edwards, 2007). In CBT the use of images is very common, being already widely used as an exposure component. Recently imagery rescripting regained popularity in research among scientists who are willing to examine its value to therapy (Holmes, Arntz & Smucker, 2007). Studies describe rescripting therapy as a technique in which the therapist asks the patient to relive an old painful memory by imagination. When this memory is generated by the patient and causes distress, the patient will try to relive this memory in a different, less painful way. For example, if the patient is reliving a situation involving an aggressor who is going to hurt the patient, the patient can imagine a third person in this situation who scares the aggressor away. The result is a more safe environment in this memory. This imaginal reliving of the situation suggests the option that the situation in the memory is controllable, which could lead to less distress. In current research, CBT is seen nowadays as the most effective treatment for various anxiety disorders (Hofmann & Smits, 2008). It focuses on weakening the stimulusresponse effect of fear arousing stimuli, for instance through exposure or by verbally challenging these undue fear responses. Studies show that learning these stimulusresponses, or unlearning them, can occur without a present stimulus. Therefore it seems possible to learn by imagination (Field, 2006). Performing elements of CBT therapy, like exposure in vivo, tends to be very stressful for the patient. Imagery exposure can be stressful for the patient as well, for instance reliving war scenes or sexual abuse. Furthermore, negative imagery is associated with psychopathology, negative imagery associated with bad moods which may lead to mood disorders (Patel et al., 2007; Williams & Moulds, 2007) and intrusive images causing a lot of distress in patients suffering from PTSD (Kindt et al, 2007; Long, Hammons et al, 2011). As intrusive memories are indicated as blockages for the recovery of the patient, it is desirable that therapists are aware of techniques to tackle symptoms of intrusive imagery. In this review, the technique of imagery rescripting will be examined in the context of treating depressive disorder, anxiety disorders and PTSD. Studies from the past 10 years will be used to describe efficacy of this treatment. In the studies, rescripting is combined with exposure in vivo, imagery exposure, or given as a standalone treatment. The mentioned disorders are described on the basis of the DSMIV. All the articles are written during years when the
DSMV was still under construction. The scales and inventories used are therefore based on the DSMIV. The main difference between the two is the fact that PTSD is no longer part of the anxiety disorders in DSMV. In the DSMV, PTSD is described as a separate disorder and therefore will be described separately from anxiety disorders in this review. This thesis will start with describing studies focussed on mood images linked to mood disorders. The effect of change in negative images on mood disorders will be examined. Afterwards imagery in anxiety disorders will be discussed and rescripting therapy for various disorders will be examined. As intrusive images are a common symptom of PTSD, studies reporting multiple distinctive intrusive images in patients (Holmes et al., 2005), the main part of research is performed using imagery rescripting to treat PTSD. This will be discussed in the final part of this review. The discussed studies all together might show us if imagery rescripting used as combined or standalone treatment reduces symptoms of Depressive Disorders, Anxiety Disorders and Posttraumatic Stress Disorder. Imagery Rescripting as treatment for Depressive Disorder Depressive patients experiencing intrusive images tend to show significant reduction in distress and lower scores at Beck’s Depression Inventory (BDI) (Beck et al., 1961), if treated with imagery rescripting. At least according to Wheatley et al. (2007) who studied two patients at a local London clinical psychology service. The two patients were followed for 9 to 13 weeks. The participants were asked to fill out the BDI on a weekly basis and to rate the level of intrusions for the week prior to every session. Intrusions in this study, as well as the studies that will be described later on, are scored on a 0 (none of the time) to 100 (all the time) scale. The participants were given imagery assignments during therapy without verbally challenging them. The patients had a baseline BDI of approximately 40 (three week baseline), which is known as severe depression. After treatment of 913 weeks and during followups after 3 and 6 months both patients did not meet the criteria for depression (BDI<10). As this study only contained two participants, the results can not be generalized to society. However, the results are a motivator for further research with more participants. Further research was performed by Brewin et al. (2009), who followed ten patients suffering from major depressive disorder. The patients were on a waiting list for standard treatment of depression, with a mean BDI of 34.1 (3 week baseline) and an average of 2.0 distinct intrusive memories. 7 Patients used prescribed medication and one dropped out of treatment after the first session. After 8 weeks of treatment the average reduction on BDI was 16.6
(p<.01). After 12 months follow up the mean BDI was M=14.5. 6 Patients showed clinical improvement as well with BDI scores under 10. The scores on the intrusion scale also decreased from 60 to 24 (p<.01). These results are promising, however this study also used a small sample group and there was a lack of control groups. Summarized the results of the two studies suggest that imagery rescripting can be used to treat depressive disorder as well as suggesting that further research is recommended. Imagery Rescripting as treatment for Anxiety Disorders Dibbets, Poort & Arntz (2012) examined the use of imagery rescripting to prevent fear renewal. In this study 60 psychology students participated in a fear conditioning project. The participants were conditioned with fear, which was followed by an extinction phase with imagery rescripting, unrelated imagery or no instructions. Fear was rated by the participant and measured by skin conductance responses. Results show that fewer fear renewal occurs in the rescripting condition compared to the no instructions condition (p<.05). Skin conductance reported no difference in response, no renewal was found. Tough little, the results are evidence of imagery rescripting connected to a reduce of anxiety symptoms. This was tested without actual phobic patients but instead the study was performed using students with conditioned fear. This raises the question if this technique can be of use in practice with actual anxiety disorders. In treatment of snake fear, imagery rescripting was used and compared to in vivo exposure (Hunt & Fenton, 2007). The participants were 52 students with selfreported fear, who at baseline couldn’t touch a snake. They were randomly assigned to one of the four groups; imagery rescripting, exposure in vivo, imagery rescripting combined with exposure in vivo or relaxation control. Self reported distress caused by the fear was measured with Subjective Units of Distress (SUD). A Behavior Approach Test was used to test the response to fear. Results show that the treatment groups scored significantly better than the nontreatment group. No difference was found between the treatment groups. This suggests that imagery rescripting is as successful as in vivo exposure in treatment of symptoms of anxiety. Noteworthy is the fact that the examined group was not in clinical fear. This raises the question if the results found in this study can be found in treatment of severe phobia as well. Social phobia is partly inflicted by negative selfimages, which are often linked to earlier socially traumatic events (Wild & Clark, 2011). Early painful memories are examined in their relation to the maintenance of anxiety disorders (Nilsson, Lundh & Viborg, 2012). 14 Patients
who did not yet receive any treatment, but met the criteria for Social Anxiety Disorder (SAD) for DSM IV, participated in this study. Participants were scored on two tests: Fear of Negative Evaluation (Watson & Friend, 1969) and Social Interaction Anxiety Scale (SIAS) (Mattick & Clarke, 1998). The treatment group got just one session of memory rescripting, they were scored before session, after session and at follow up one week later. The control condition was scored before and after a reading task and at one week follow up. Results show significant differences in decrease of symptoms of fear of negative evaluations (p=.03), anxiety for social interaction (p=.03) and memory distress (p<.01) comparing the two conditions after treatment, all in favor of rescripting therapy. At follow up all scores were even more decreased. This results suggest social improvements enhanced by rescripting intervention. It is however essential to mention that after one week there had been no more follow up and significant decrease of distress is not necessarily clinical improvement. Frets, Kevenaar & Van Der Heijden (2014) studied whether imagery rescripting as standalone treatment tends to be effective in treatment of social phobia. 6 Patients diagnosed with social phobia were assessed for three weeks to set up a baseline of their symptoms. The participants were scored on a Dutch version of the SIAS and the Social Phobia Scale (SPS) (Mattick & Clarke, 1998). Imagery rescripting as standalone treatment was used with all patients, no verbally challenging was encouraged of any beliefs. Patients were treated for 5 up to 17 weekly sessions before final assessment. All patients clinically recovered, and this effect was maintained at follow up at 3 and 6 months. This suggests that imagery rescripting as standalone treatment decreases anxiety symptoms in social phobics. The results of these studies suggest that imagery rescripting might be effective in treatment of various anxiety disorders. There is some evidence of the treatment being effective in preventing or reducing symptoms of different disorders. Implications based on this results are however limited, as the studies lack large clinical samples or evident control groups. Imagery Rescripting as treatment for PostTraumatic Stress Disorder One of the symptoms of PTSD is having trauma related intrusions. These intrusions are experienced in combination with fear for reliving the past experience or fear for the trauma happening again. Imagery rescripting focusses on reprocessing the memories on which the intrusions are referring to. As before suggested in this thesis, imagery rescripting tends to be effective as treatment of anxiety. As PTSD has some similar grounds and symptoms as anxiety, it might be of influence in treatment of PTSD as well. This will be described in a few
steps. First the effects of imagery rescripting on treatment of Posttraumatic Nightmares (PTNMs) will be described, secondly the effects of imagery rescripting on treatment of PTSD. Sleep disturbance is very common in PTSD. About 80% of the patients reports this disturbance. Approximately 70% of these patients reported chronic PTNMs (Long, Davis et al., 2011). Referring to these nightmares in research needs interest, as sleep disturbance tend to predict clinical and other distress outcomes (Belleville, Guay, & Marchand, 2009). In a study on veterans diagnosed with PTSD, imagery rescripting and exposure treatment was given to decrease the nightmares reported (Long, Hammons et al., 2011). The 37 veterans were all male and the majority of them had no prior experience with treatment for PTSD. The veterans had seeked help especially to reduce their nightmares as they described those as very disturbing. In some cases it had affected their sleep for multiple decades. The participants were followed during a 6session imagery rescripting and exposure group treatment. Imagery rescripting was the main treatment technique for 50% of the sessions. After treatment 90% of the participants reported improvement in less nightmares and more hours sleep. Mean of the nightmares went from 4.8 a week to 2.4 a week. With 15.2% reporting no more nightmares. There were improvements on the PTSD Checklist for Military (PCLM) (Weathers et al., 1994), with M=68.7, SD=11.1 at the start of session one to M=55.7, SD=14.8 at the end of treatment. Also 10 veterans (27%) no longer met the criteria for PTSD. This study suggests imagery rescripting therapy reduces PTNMs of veterans. It is possible that this group of patients have a poor generalizability, it is also worrisome that no control group is used in this study. Assuming the results are valid, it would be interesting to explore why these results are found. The following study will first discuss the cognitive changes that are followed by nightmare treatment. A group of 40 patients and nonpatients who suffered from PTNMs for at least 3 months participated in a 3 session intervention of Exposure, Relaxation and Rescripting Therapy (ERRT) (Davis, 2009). Their negative cognitions were scored in an attempt to examine a connection between the reduce of negative cognition and the decrease of PTSD symptoms (Long, Davis et al., 2011). The participants were randomly assigned to either a therapy condition or a control condition. The therapy consisted of three sessions of combined psychoeducation, exposure therapy and rescripting therapy including homework assignments. The results of 19 participants included at least 3 of the 4 scores (baseline, 1 week posttreatment, 3 months and 6 monthsfollow up) on the Posttraumatic Cognitions Inventory (PTCI) (Foa et al., 1999) and were therefore included in the examination. On average the
PTCI scores decreased by 1.48 points from 12.01 at start to 10.53 at 6 months follow up, meaning that there were less traumatic thoughts after treatment. A correlation was found between decrease in negative beliefs and decrease in PTSD symptoms (r=.49, p=.017). When divided into sub scales one scale was found to be correlated to PTSD as well, decrease in negative self beliefs was correlated with decrease in PTSD symptoms (r=.58, p<.01). The outcomes of this study suggests that the use of imagery rescripting for PTNMs results in less posttraumatic cognitions and a decrease of negative beliefs, which tends to be correlated to a decrease in posttraumatic stress disorder symptoms. The change of negative beliefs might be linked to other symptoms of PTSD as well, like intrusions and flashbacks. Commonly used treatment like prolonged exposure is focused on how to handle the trauma and intrusions followed by the trauma, is does not focus on changing the negative beliefs about cognition or about the self. This proposes the question if imagery rescripting can be useful to influence these symptoms by setting the focus of therapy on the change of negative cognition about self and intrusions. Kindt et al. (2007) examined the influence of improved conceptual processing on treatment outcome in the treatment of PTSD. The results of 25 patients who suffered from PTSD for at least 3 months were analyzed for this study. The participants did not have prior treatment for PTSD, which led them to their first CBT treatment. This was a combined treatment with imagery exposure and imagery rescripting. The treatment had weekly sessions of about 90 minutes and homework assignments for 10 weeks. Imagery exposure and rescripting were part of every session. The patients were scored on the PTSD Symptom Scale (PSS) (Foa et al., 1993) and the state anxiety part of StateTrait Anxiety Inventory (STAI) (Spielberger et al., 1970) prior to treatment, after the last session and at 1 month follow up. Two independent master students were trained to rate the memories that were told by the patients during treatment. The raters scored the memories of every session as more conceptual or more perceptual on a 9 point scale, with 1 for exclusively conceptual and 9 for exclusively perceptual. Compared to pretreatment the means of PSS and STAI were decreased significantly after 10 sessions (p<.01) and at follow up (p<.01). This shows the therapy was somewhat effective. Multiple regression analyses were performed for this study to examine any link between conceptual/perceptual processing and PTSD symptoms. Initial increase of perceptual processing significantly explained 21% of the change in symptoms after follow up. Later change of processing to conceptual explained an extra 16%. Further exploration of results shows that initial change to perceptual processing has a positive effect on the
decrease of PTSD symptoms, ónly when a later change of processing occurs in direction of conceptual processing. This study subsequently suggests the possibility that change in cognitive processing is the or one of the active components of imagery rescripting. The following study examines the change patients, who are not responding to prolonged exposure (PE), go through after treatment with imagery rescripting (Grunert et al, 2007). In a study of 125 injury victims who met criteria for PTSD, 23 patients did not respond to treatment with PE. After no change in 6 to 15 sessions the therapist decided to start a new treatment that included rescripting as imagery component. It was remarkable to notice that the patients in this group filed their most important emotion regarding to the injury as guilt and anger. Nonfear emotions, in this case guilt and anger, were noted as predominant in this patients. After failed sessions of prolonged exposure, Imagery Rescripting and Reprocessing Therapy (IRRT) was given for 3 sessions. The symptoms of the participants were measured on the BDI and the Impact of Event Scale (IES) (Horowitz et al., 1979) for avoidance and intrusions. The patients were scored before PE, after PE/before IRRT, directly after the last session of IRRT and at 6 months follow up. Before the first session the means of IES were 21.96 for avoidance and 21.83 for intrusions, these scores dropped by 6.78 and 8.22 points (p<.01) after the last session and were decreased even more at follow up after 6 months. The mean of BDI decreased from 22.00, that indicates a moderate depression, to 14.96 (p<.01) and after 6 months follow up the mean score met the criteria for minimal depression. After 3 sessions of IRRT 79% of the participants did not met the criteria of PTSD anymore and it sustained for at least 6 months. This suggests that patients who suffer from PTSD do not respond to regular treatment in the same way. Apparently patients with PTSD who have guilt or anger instead of fear as their most painful emotion are reacting to imagery rescripting more than prolonged exposure. Disadvantages of this study are the lack of control groups and a small sample. Further research is desirable when more participants are used. Arntz, Tiesema & Kindt (2007) examined 67 patients who met criteria for PTSD with symptoms for at least 3 months but who have had no prior therapy for PTSD. The participants were randomly assigned to a waiting list, Imagery Exposure (IE) or IE with Imagery Rescripting (IR). The PTSD symptoms were measured with the PSSSelf Scoring, influences of therapy were measured by having the participants fill out a questionnaire called Expectancy of therapeutic outcome. This questionnaire is focussed on the therapeutic expectations of the participants. It is scored by three questions on a 9points scale, for example; ‘How much confidence do you have that the proposed treatment will resolve your problems?’. The
participants were also scored on their feelings of anger, shame and guilt. There were at least 8 weeks of 90 minutes weekly treatment, otherwise the participant would be considered as dropout. The first three sessions were the same in the treatment conditions. Starting from the fourth session, imagery rescripting was used for 60 minutes each session in the IEIR condition. The treatment conditions showed a decrease on the PSS, M=27.20 at pretreatment and M=16.20 at posttreatment (p<.01). Between the two therapy conditions there was no difference in outcome on the PSS, expectations scale, anger scale or shame scale. On the other hand there was a difference in dropout; less dropout in the IE+IR condition compared to IE condition (51% to 25%, p=.03) and the participants in IE+IR showed less feeling of guilt at posttest (p=.02). These results suggest that imagery rescripting can be an effective combined treatment with imagery exposure for PTSD, but has no difference in outcome compared to IE alone. However there was a difference in dropout, showing less dropout in the rescripting condition. Based on previously mentioned studies there are factors like anger, shame and guilt that might affect the therapy (Grunert et al., 2007). These factors together with expectation of therapy are measured in this study as well, however only a change in feelings of guilt is found to be different between the two treatment conditions. The not declared difference in therapy progress between imagery rescripting and imagery exposure has lead to a search for possible causes. Previous studies has not merely examined fear or fear responses in relation to PTSD. Also emotional reactions like anger, shame or guilt are taken into account, Arntz et al. (2007) even examined expectations of treatment. Although no effect was found in that case, there has been a continuation of examination in other possible causes. Hoffart et al. (2013) examined the connection between the components of alliance and symptoms of PTSD for imagery exposure compared to imagery rescripting. 65 Patients suffering from PTSD were assigned to prolonged exposure treatment with either IE or IR as imagery component. The participants received 90 minutes of weekly treatment for 10 weeks and were measured pretreatment and every monday on PTSD symptoms, by scores on the PSSSS. They were also scored for alliance, by scores on the Working Alliance InventoryShort Revised (WAISR) (Hatcher & Gillaspy, 2006). During the weeks of treatment the participants scored this inventory each friday on three components of alliance, namely task, goal and bond. The first two sessions were the same for both conditions, providing treatment rationale, trauma education and planning. Also exposure in vivo was introduced. The two conditions differed during the third till ninth session, where imagery rescripting replaced imagery exposure for 40 to 60 minutes. After the 10th and last session, which was
the same again, the participants were tested for the last time. The results show no difference between the two types of therapy. A withinsubject result was found that shows if the participant declared to have a stronger agreement on tasks, the participant shows less PTSD symptoms than expected three days later. No such results were shown for the other components of alliance. Initial higher alliance on task agreement was also associated with lower PTSD symptoms, as well as initial higher alliance on bond. Task alliance was furthermore associated with outcome in the imagery exposure condition. Altogether alliance seems to influence the therapy just slightly and this effect is more associated with imagery exposure than it is with imagery rescripting. The studies mentioned above all suggest imagery rescripting is effective in treatment of PTSD, however the studies are based on therapeutic techniques that combine rescripting with the usual exposure. Some combine it with imagery exposure, some with in vivo and some with both. Though combined treatment shows promising results regarding treatment outcome. Studying this treatment combined leaves no certainty of the outcome being due to the part of imagery rescripting. To examine if rescripting is effective per se, Arntz et al. (2013) conducted a study, using imagery rescripting as standalone treatment. 10 War refugees with PTSD, found at a Dutch mental health care institute participated in this study. The participants were measured for 6 to 10 weeks to set a PTSD symptoms baseline. Thereafter a 5 week trauma exploration phase started, where the trauma was accurately reported by the patient but no therapy was given. A 10 week phase of imagery rescripting as standalone treatment followed. At last there were two moments of follow up assessment, after 5 weeks and after 3 months. PSS scores were measured at baseline, after every session and at follow ups. The average score at baseline was M=28.03, which suggests PTSD. After treatment the average score decreased significantly to M=11.62, p<.01. In this study a cutoff score of 14 was used to decide whether the patient suffered from PTSD or not, following this measure 90% of the patients did not meet the criteria for PTSD anymore at follow up. Given the fact that the patients were suffering for PTSD up to 27 years, M=13.1, this effect can be called startling. Also the one patient who did not recover after treatment revealed he had more problems dealing with his sexual identity than being a war refugee. As this study uses a small sample of patients, who all used prescribed medication, further research with more participants of various populations is wanted. This does however contributes to the evidence that imagery rescripting can be used as standalone treatment of PTSD.
The use of imagery rescripting seems to enhance even more possibilities. The following described study suggests it is possible to reduce the development of intrusions by providing imagery rescripting as preventer (Hagenaars & Arntz, 2012). 76 Students watched a 10minutes film to imitate a traumatic experience. Thereafter they were randomly assigned to a short intervention of positive imagery, imagery reexperiencing or imagery rescripting. The participants then kept daily notes about the amount of intrusive images they experienced for the next 7 days. The PTCI was used to score negative cognitions after the 7 days. And at last explicit memory was measured after the 7 day period by 12 open questions about the modelled trauma. At this moment results of different conditions were compared and a difference was found in amount of intrusive images, there were significantly less intrusions in the rescripting condition compared to the others, p<.01 and p=.05. PTCI scores were lower for rescripting and positive imagery compared to reexperiencing, p=.02 and p=.03. Which suggests that overall less negative cognition does not causate intrusions. At last, compared to positive imagery, the explicit memory task was performed better by both rescripting, p=.03, as reexperiencing, p=.02. This suggests that the fact that memories were better remembered did not affect the amount of intrusions. However there is no clinical sample used in this study to describe the differences. These results suggest that PTSD symptoms could partly be prevented by imagery rescripting. This sample population is not generalizable to a clinical population, therefore this study should be replicated with clinical participants in the future. Discussion Research discussed in this thesis suggests that imagery rescripting is an effective treatment of depressive disorder, anxiety disorders and PTSD. Most studies described in this review practiced imagery rescripting as combined or partly combined treatment with imagery exposure. This turned out to be an effective combination. Furthermore also the standalone treatment of imagery rescripting shows promising results. Remarkable was the small amount of dropouts during treatment and the difference in dropout rates between rescripting and exposure, as rescripting led to less dropout. Results also show that imagery rescripting seems to be effective after failure of prolonged exposure which suggests that treatment with rescripting affects different elements of disorders than exposure. Emotions like anger, shame and guilt are proposed to be influenced by rescripting. Study results differ, a clear conclusion can not be based on these studies only. However suggestions can be made. Feelings of anger and especially guilt seem to be more affected by the rescripting therapy. As this is
evidence of imagery rescripting affecting different parts of disorders than common treatment, there are some suggestions for further use of imagery rescripting. For instance imagery rescripting can be used as supplementary technique as it likely treats additional cognitive or emotional dysfunctions. As there is some evidence of imagery rescripting being effective as standalone treatment as well, imagery rescripting might be used as substitution of usual treatment. The results described above show that rescripting treatment has a lower dropout rate than exposure treatment. Therefore it might be more effective, as lower dropouts can reach more successfully finished treatments. It is useful to examine and discover why rescripting leads to less dropout. These findings might tell us how to improve therapy so that patients are more accommodating to treatment. Also could this low dropout rates indicate that rescripting is more likeable than exposure, which with equal treatment results is in favor of rescripting Unfortunately limitations of the research are present. With small sample sizes and lack of control groups, the results of a large part of the studies can not be used to make strong conclusions. The studies do however induce occasions for further research, including control group designs and larger sample sizes. Also some of the studies are based on assessment of non clinical populations. The results of participants with conditioned fear or trauma may not be generalizable. It is important to perform similar research with the use of clinical participants. As suggested above, different emotions might lead to different responses to treatment. Identifying predominant emotions before the start of treatment might show how various patients react to different uses of imagery. In the future this will assist to decide whether rescripting treatment is of use and if it should be added to treatment or replace it.
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