برنامه نویسی مجدد تصویرسازی به عنوان یک درمان مستقل برای بیماران مبتلا به هراس اجتماعی: مجموعه ای مورد

Abstract Background and objectives The majority of patients with social phobia reports experiencing negative images, usually linked to memories of earlier aversive social experiences. Several studies have indicated that such negative self-imagery appears to have a causal role in maintaining social phobia, which suggests that interventions aimed at dealing with these images could be beneficial in the treatment of social phobia. One potentially powerful approach is imagery rescripting (IR), a clinical intervention that focuses on changing the meaning and impact of unpleasant memories. In the treatment of social phobia IR was only used as part of a broader cognitive-behavioral treatment package. However, we propose that IR alone might also be an effective treatment for this anxiety disorder. The present study reports an initial evaluation of the application of IR as a stand-alone treatment for six adult outpatients presenting with social phobia. Methods A single case series using an A-B replication across patients design was employed. Following a no-treatment baseline period, IR was delivered weekly and patients were followed up for 3 and 6 months. Results For all patients, substantial reductions were obtained on all outcome measures at post-treatment, and gains were largely maintained at 6-months follow-up. Limitations The generalizability of the effects of IR for social phobia is limited by the small number of patients treated by only one therapist. Conclusions The results of this preliminary case series suggest that IR as a stand alone treatment is an apparently effective intervention in the treatment of patients with social phobia, and indicate that controlled evaluation of its efficacy might be worthwhile.

The majority of patients with social phobia reports experiencing negative, observer-perspective images, which elicit anxiety as they represent what patients fear (Hackmann, Surawy, & Clark, 1998). These negative images are usually based on memories of earlier aversive social experiences, that cluster around the onset of the disorder (Hackmann, Clark, & McManus, 2000). The way patients appear in the intrusive negative self-images remains stable and constant across many different social situations, despite subsequent more positive experiences (Clark, 2005 and Hackmann et al., 2000). Several studies have indicated that negative self-imagery appears to have a causal role in maintaining social phobia by increasing state anxiety, enhancing unrealistically negative self-judgments, and having a detrimental effect on performance and the social situation in general (Hirsch et al., 2003 and Hirsch and Holmes, 2007). Given the detrimental impact on patients with social phobia, interventions aimed at successfully dealing with negative images should have a useful therapeutic effect. One potentially powerful approach is imagery rescripting (IR), in which memories of traumatic social situations, which form the basis of negative self-images, are restructured by imagining that the course of events is changed in a more desired direction (Arntz, 2012, Wild and Clark, 2011, Wild et al., 2007 and Wild et al., 2008). IR involves having patients revisiting their memory in three stages. First, patients are asked to relive a past traumatic social experience from the age at which it occurred (reliving stage). In the second stage, patients first relive the event again, but this time from the perspective of their current age observing what is happening to their younger self, and are then invited to intervene in the situation, e.g. by imagining themselves entering the situation as an adult helping their younger self (mastery stage). In the third and final stage, the patient relives the rescripted scene from the perspective of their younger self (compassionate stage). IR was originally developed for adult survivors of childhood trauma (Arntz and Weertman, 1999 and Smucker et al., 1995). To date, IR is integrated in several well-established CBT packages for PTSD, social phobia, nightmares, personality disorders (see Arntz, 2012), and is also used as a stand-alone treatment in cases of PTSD and depression (e.g. Brewin et al., 2009 and Grunert et al., 2003). So far, a limited number of studies has provided support for the efficacy of one session of IR as part of, or preceding a broader cognitive behavioral treatment package for social phobia (Wild et al., 2007 and Wild et al., 2008). More recently, IR was found to be efficacious as a stand-alone treatment (i.e., without explicit logical or verbal restructuring; Nilsson, Lundh, & Viborg, 2012), with effect sizes matching those of IR with cognitive restructuring as found by Wild et al. (2008). Although not having directly tested the relative effectiveness of IR with, or without cognitive restructuring, results of this study strongly question the need of cognitive restructuring. The present study reports an evaluation of the application of IR as a stand-alone treatment for six patients presenting with social phobia, using a single-case design. We predicted that IR would result in a significant reduction of symptoms of social phobia.

Each patient's scores on the SIAS, SPS and the AVS during the baseline and treatment periods, and at follow-up are shown in Figs. 1 and 2. The baseline scores were not stable for each patient across all three outcome measures. Patient 6 showed a decrease on the SIAS, whereas patient 2 and 5 showed an increase on this measure. Patient 5 also showed an increase on the SPS. Furthermore, on the AVS patient 4 and 6 showed a decrease in avoidance in the baseline period, whereas patient 4 also showed an increase in anxiety. Each patient showed substantial reductions in interaction anxiety, performance anxiety, and degrees of anxiety and avoidance related to their five idiosyncratic situations over the course of treatment. These gains were largely maintained at the follow-up assessment points. Full-size image (60 K) Full-size image (57 K) Fig. 1. Scores on the Social interaction anxiety scale (SIAS) and Social phobia scale (SPS) for the 6 patients during baseline, treatment and follow-up. Figure options Full-size image (55 K) Full-size image (60 K) Fig. 2. Scores on the Anxiety and avoidance scale (AVS) for the 6 patients during baseline, treatment and follow-up. Figure options Data for each patient on SPAI-N, BFNE and BAI at pre- and post-treatment, and follow-up assessments are shown in Fig. 3. For each patient, post-treatment scores were lower than pre-treatment scores on all measures. Percentage improvement from pre- to post-treatment on the SPAI-N for patient 1 was 46%, patient 2, 85%, patient 3, 53%, patient 4, 35%, patient 5, 60%, and patient 6, 12%. On the BFNE, the percentage improvements were as follows: patient 1, 65%, patient 2, 48%, patient 3, 22%, patient 4, 25%, patient 5, 17%, and patient 6, 45%. On the BAI, the percentage improvements were as follows: patient 1, 58%, patient 2, 43%, patient 3, 25%, patient 4, 33%, patient 5, 30%, and patient 6, 50%. However, results were less clear-cut at the follow-up assessment. On the SPAI-N and BFNE, only three patients continued to improve their scores during follow-up. With the exception of patient 6, whose follow-up score on the SPAI-N was higher than the pre-treatment score on this measure, the other scores at follow-up represented a slight deterioration, but they continued to represent a substantial reduction from pretreatment assessment. As such, in terms of percentage improvement almost all patients improved from pretreatment to follow-up on the SPAI-N, patient 6 deteriorated (17%), but the other five patients improved: patient 1, 56%, patient 2, 54%, patient 3, 58%, patient 4, 67% and patient 5, 60%. On the BFNE all patients improved from pretreatment to follow-up: patient 1, 22%, patient 2, 43%, patient 3, 52%, patient 4, 44.%, patient 5, 31%, and patient 6, 59%. On the BAI, only one patient (4) experienced a further decrease. Two patients (1 and 2) experienced an increase, but their follow-up score still represented a substantial improvement as compared to pretreatment assessment. However, the follow-up scores of patient 3 and 6 increased to the level of their pretreatment scores. This was reflected in the percentage improvement from pretreatment to 6 months follow-up on the BAI: patient 1, 33%, patient 2, 36%, patient 3, 0%, patient 4, 72%, patient 5, 10%, and patient 6, 0%. Full-size image (52 K) Fig. 3. Scores on the Social phobia subscale of the Dutch social phobia inventory (SPAI-N), the Brief fear of negative evaluation scale (BFNE) and the Beck anxiety inventory (BAI) at the beginning of the baseline period, at post-treatment and 6 months follow-up for each patient.