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

BACKGROUND AND OBJECTIVES: Posttraumatic stress disorder (PTSD) related to childhood abuse (CA) is associated with high symptom complexity. This study examined the efficacy of Imagery Rescripting (ImRs) as a stand-alone treatment versus a sequenced approach with Skills training in Affective and Interpersonal Regulation (STAIR) followed by ImRs for CA-related PTSD. METHODS: Outpatients of two mental health clinics with CA-related PTSD (N = 61) were randomly assigned to ImRs (16 sessions; n = 21), STAIR/ImRs (8 STAIR-sessions followed by 16 ImRs-sessions; n = 20), or Waitlist (8 weeks; n = 20). Patients of the waitlist condition were also randomized to the two active conditions for comparison of STAIR/ImRs (total n for this condition = 31) and ImRs (total n for this condition = 30) and started treatment after waitlist completion. Assessments took place at pre-treatment, after each treatment phase and at 12-week post-intervention follow-up. PTSD symptoms and diagnosis were primary outcome measures, and depression, emotion regulation and interpersonal functioning were secondary outcomes. RESULTS: ImRs showed greater reduction of PTSD severity (effect sizes [ES] 1.40-1.63) than STAIR (ES, 0.23-0.33) as compared to waitlist. When comparing STAIR/ImRs and ImRs directly, (i.e. including re-randomized Waitlist-patients), PTSD symptoms reduced significantly (within condition ES, 1.64-2.10) and improved further to 12-week follow-up (within-condition ES, 2.33-2.66), with no significant difference between both conditions (between-condition ES, 0.21-0.45). Loss of PTSD diagnosis was achieved by 70% in the ImRs condition and 86% in the STAIR/ImRs condition. LIMITATIONS: The sample size was relatively small. CONCLUSIONS: Results show that ImRs is an effective treatment for CA-related PTSD, whereby the current data do not convincingly show an additive effect of STAIR.

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.

Efficacy of imagery rescripting and imaginal exposure for nightmares: A randomized wait-list controlled trial.

Nightmares can be effectively treated with cognitive-behavioral therapies. Though it remains elusive which therapeutic elements are responsible for the beneficial effects on nightmare symptoms, imagery rescripting (IR) and imaginal exposure (IE) are commonly identified as active treatment components of nightmare therapies. With this randomized controlled trial, we compared IR and IE as individual treatments to a wait-list (WL) condition to determine whether these particular therapeutic elements ameliorate nightmare symptoms. For this purpose, 104 patients with a primary DSM-5 diagnosis of nightmare disorder were randomly assigned to three weekly individual sessions of either IR or IE, or WL. Results showed that compared to WL, both interventions effectively reduced nightmare frequency (ΔdIR-WL = 0.74; ΔdIE-WL = 0.70) and distress (ΔdIR-WL = 0.98; ΔdIE-WL = 1.35) in a sample that predominantly consisted of idiopathic nightmare sufferers. The effects of IR and IE were comparable to those observed for other psychological nightmare treatments. Initial effects at post-treatment were sustained at 3- and 6-months follow-up, indicating that IR and IE both seem to be efficacious treatment components of nightmare therapies. Additional research is needed to directly compare IR and IE among both idiographic and posttraumatic nightmare sufferers with respect to treatment expectancy, acceptability, and effectiveness.

Pathways towards the proliferation of avoidance in anxiety and implications for treatment.

Avoidance is a key symptom of anxiety disorders. Maladaptive avoidance impairs general functioning acutely and maintains chronic anxiety. A better understanding of the mechanisms that elicit and maintain excessive avoidance might provide opportunities to improve treatment. Here, we discuss pathways through which avoidance might get amplified in the context of anxiety disorders: 1) increased threat appraisal; 2) enhanced threat avoidance tendencies; 3) impaired regulation of avoidance; 4) habitual avoidance; and 5) attempts at increasing psychological distance. Novel strategies for reducing avoidance are considered. These include memory reconsolidation interference, retraining of avoidance tendencies, mindfulness training and habit disruption approaches. Throughout the paper, we highlight a number of suggestions for future research on avoidance and how to achieve lasting behavior change.

Efficacy and mechanisms of imagery rescripting and imaginal exposure for nightmares: study protocol for a randomized controlled trial.

BACKGROUND: Recurrent nightmares can effectively be treated with cognitive-behavioral techniques such as imagery rehearsal therapy, which involves imagery rescripting (IR) of nightmares, and imaginal exposure (IE) therapy. However, the underlying mechanisms of these treatments remain largely unknown. To investigate this, we identified a number of variables that might mediate the therapeutic effect of rescripting-based and/or exposure-based therapies. Also, to control for the possible confounding influence of (other) treatment components, we designed two stripped-down treatment protocols, which primarily consist of either (1) rescripting of, or (2) exposure to, the nightmare content. In a randomized controlled trial, we aim to investigate the therapeutic efficacy of these stripped-down IR and IE treatments, and explore their working mechanisms. METHOD: Three weekly sessions of either IR or IE will be compared to a waiting-list control group. Ninety participants suffering from nightmare disorder will be included and randomly allocated to one of the three groups. The primary clinical outcome measures are nightmare frequency and distress caused by nightmares. Secondary clinical outcome measures include sleep complaints, dysfunctional beliefs about nightmares, and posttraumatic stress symptom severity. Outcomes will be assessed weekly from week 1 (pre-assessment) to week 5 (post-assessment). Online follow-up assessments will take place at 3 and 6 months after post-assessment. In order to investigate temporal relationships between mediators and outcome, we will measure the proposed mediators of the treatment effect 1 day after each outcome assessment (but not after the follow-ups). Mediators include nightmare distress and valence, mastery of the nightmare content, predictability, controllability, and tolerability of emotions elicited by nightmares, as well as sleep quality. DISCUSSION: The proposed trial allows us to investigate the efficacy of IR and IE as intervention techniques for the treatment of nightmares, and to explore mediators of their respective therapeutic effects. The results may advance our understanding of nightmare therapies by identifying possible mechanisms of psychological treatments for chronic nightmares. Moreover, the results of the proposed study might provide useful knowledge about the working mechanism of rescripting-based and exposure-based treatments in general. TRIAL REGISTRATION: Netherlands Trial Register ( NTR4951 ), registered on 14 December 2014.

Imagery Rescripting as stand-alone treatment for posttraumatic stress disorder related to childhood abuse.

OBJECTIVE: This case series tested the feasibility and explored the efficacy of Imagery Rescripting (ImRs) as a stand-alone treatment for PTSD related to childhood physical and/or sexual abuse (CA). METHOD: Participants (6 women and 2 men) were patients with PTSD related to CA who entered an 8 week treatment program with 16 twice-weekly ImRs sessions. Blind assessments took place at pre- and post-treatment and at 3 month follow-up. RESULTS: Participants showed improvement in both self-reported and clinician-rated PTSD symptoms. Gains were maintained at 3-month follow-up. At post-treatment, 50% of participants no longer met criteria for PTSD, and this number increased to 75% at 3 month follow-up. LIMITATIONS: The main limitation is the small sample size and the selective nature of the sample, which limits the generalizability of the findings. CONCLUSIONS: This pilot study suggests that Imagery Rescripting as stand-alone treatment is feasible and effective without prior stabilization in an outpatient population with CA-related PTSD. Further replication is needed in form of a randomized controlled trial.

The effects of noradrenergic blockade on extinction in humans.

The process of reconsolidation has attracted much attention because of its potential application for the treatment of psychiatric disorders. Here, we investigate a possible boundary condition of disrupting reconsolidation with the noradrenergic antagonist propranolol in humans. Reconsolidation can be initiated by retrieval of an acquired fear memory, which is in procedure equivalent to extinction training. If memory retrieval promotes the formation of a novel extinction memory trace, propranolol may interfere with extinction rather than with reconsolidation. Using a differential fear conditioning paradigm, we demonstrate that administration of propranolol (double-blind placebo controlled) prior to repetitive unreinforced CS presentations did not affect extinction at a physiological level (startle reflex and skin conductance). At a cognitive level, propranolol directly impaired extinction learning. These findings indicate that careful selection of timing parameters is essential to ensure that pharmacological agents interfere with the intended memory process to reduce fear.

Beyond extinction: erasing human fear responses and preventing the return of fear.

Animal studies have shown that fear memories can change when recalled, a process referred to as reconsolidation. We found that oral administration of the beta-adrenergic receptor antagonist propranolol before memory reactivation in humans erased the behavioral expression of the fear memory 24 h later and prevented the return of fear. Disrupting the reconsolidation of fear memory opens up new avenues for providing a long-term cure for patients with emotional disorders.

False heart rate feedback and the perception of heart symptoms in patients with congenital heart disease and anxiety.

BACKGROUND: Little is known about the mechanisms explaining an increased perception of heart symptoms in congenital heart disease (ConHD). In the present study, it was suggested that a combination of high trait anxiety and disease history increases the perception of heart symptoms. PURPOSE: It was tested whether false heart cues will result in an increased perception of heart symptoms in patients with ConHD and anxiety. METHOD: Thirty-six patients with ConHD and 44 healthy controls performed two exercise tasks. During one of the exercise tasks, participants were exposed to a false heart cue consisting of false heart rate feedback (regular or irregular). Perceived heart symptoms were assessed and heart rate, arterial partial pressure of CO(2), and respirator rate were monitored continuously. RESULTS: In line with the predictions, false heart rate feedback resulted in an increased perception of heart symptoms in high trait anxious patients with ConHD that could not be explained by acute heart dysfunction. However, unexpectedly, this effect was not observed immediately after the false heart rate feedback task but after a second exercise task without false feedback. CONCLUSION: The results suggest that not the sole presence of ConHD but ConHD in combination with high trait anxiety results in a vulnerability to overperceive heart symptoms.

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

We tested whether the effectiveness of imaginal exposure (IE) treatment for posttraumatic stress disorder (PTSD) was enhanced by combining IE with imagery rescripting (IE+IR). It was hypothesized that IE+IR would be more effective than IE by (1) providing more corrective information so that more trauma-related problems can be addressed, and (2) allowing patients to express emotions that they had been inhibiting, such as anger. In a controlled study 71 chronic PTSD patients were randomly assigned to IE or IE+IR. Data of 67 patients were available. Treatment consisted of 10 weekly individual therapy sessions and treatment evaluation was conducted post-treatment and at 1-month follow-up. Results show that when compared with wait-list, treatment reduced severity of PTSD symptoms. More patients dropped out of IE than out of IE+IR before the 8th sessions, 51% vs. 25%, p=.03. Completers and intention-to-treat analyses indicated that both conditions did not differ significantly in reduction of PTSD severity. IE+IR was more effective for anger control, externalization of anger, hostility and guilt, especially at follow-up. Less strong effects were found on shame and internalized anger. Therapists tended to favor IE+IR as it decreased their feelings of helplessness compared to IE. Results suggest that the addition of rescripting to IE makes the treatment more acceptable for both patients and therapists, and leads to better effects on non-fear problems like anger and guilt.

Preattentive processing of heart cues and the perception of heart symptoms in congenital heart disease.

The present study was aimed at clarifying whether preattentive processing of heart cues results in biased perception of heart sensations in patients with congenital heart disease (ConHD) who are also highly trait anxious. Twenty-six patients with ConHD and 22 healthy participants categorized heart-related (heart rate) or neutral sensations (constant vibration) as either heart or neutral. Both sensations were evoked using a bass speaker that was attached on the chest of the participant. Before each physical sensation, a subliminal heart-related or neutral prime was presented. Biased perception of heart-sensations would become evident by a delayed categorization of the heart-related sensations. In line with the prediction, a combination of high trait anxiety and ConHD resulted in slower responses after a heart-related sensation that was preceded by a subliminal heart cue. Preattentive processing of harmless heart cues may easily elicit overperception of heart symptoms in highly trait anxious patients with ConHD.