برنامه نویسی دوباره تصویرسازی برای اختلال وسواس: طراحی تجربی تک موردی در 12 مورد

Background and objectives Some individuals with Obsessive Compulsive Disorder (OCD) may experience recurrent intrusive distressing images, which may be emotionally linked to past aversive memories. Our aim was to investigate whether Imagery Rescripting was an effective intervention for such individuals with OCD. Method Twelve cases who experienced intrusive distressing images are presented in a A1BA2CA3 single case experimental design. After a baseline of symptom monitoring (A1), participants had a control intervention of talking about the memory related image (B), followed by symptom monitoring (A2), a single session of Imagery Rescripting (C) and further monitoring for up to 3 months (A3). Results Minimal change was seen following the control intervention. However, at 3 months following ImRs, there was a drop in the Yale-Brown Obsessive Compulsive Scale, with a decrease from a mean of 24.1 to 10.7. Reliable improvement was achieved in 9 out of the 12 cases and clinically significant change in 7 out of 12 at 3-month follow up. The limitations are that all cases were selected on the basis that they had an aversive memory linked to their imagery. Conclusions Imagery Rescripting is a promising therapeutic technique for OCD as an adjunct to CBT where intrusive images are linked to aversive memories.

Cognitive Behavioral Therapy (CBT), including exposure and response prevention, remains the psychological treatment of choice for Obsessive-Compulsive Disorder (OCD) (National Institute for Health and Care Excellence, 2005). However, a significant proportion of cases still fail to respond to CBT (Abramowitz et al., 2003, Rufer et al., 2006 and Tolin et al., 2004). This has prompted the search for new target areas for intervention, in the hope that outcomes can be improved. Imagery has long been discussed within cognitive models of anxiety disorders including OCD (De Silva, 1986 and Hackmann et al., 1998), however it is particularly prominent in post-traumatic stress disorder (PTSD) (Bisson et al., 2007 and Ehlers and Clark, 2000). Intrusive images related to the trauma are considered to play an important role in the maintenance of the disorder (Hirsch & Holmes, 2007). Intrusive imagery linked to an aversive (or traumatic) memory is experienced in a variety of other anxiety disorders, including social phobia (Hackmann, Clark, & McManus, 2000), body dysmorphic disorder (Osman, Cooper, Hackmann, & Veale, 2004), agoraphobia (Day, Holmes & Hackmann, 2004), specific phobia of vomiting (Price, Veale, & Brewin, 2012), health anxiety (Muse, McManus, Hackmann, Williams, & Williams, 2010) and in OCD (Coughtrey et al., 2013, Lipton et al., 2010 and Speckens et al., 2007). Speckens et al. (2007) found that 81% (29/37) of participants with severe OCD reported intrusive mental imagery and for 76% of these, the images was associated with subsequent engagement in compulsive behaviors. They also found that participants' OCD symptoms reportedly developed following an aversive event, something which has been noted before in some types of OCD (Coles et al., 2008, De Silva and Marks, 1999 and Lipinski and Pope, 1994). For these participants, the intrusive images held an important association, often linked to beliefs they held about themselves or their responsibilities. Those who experienced images indicated that they were associated with memories of adverse events, which might have not been emotionally processed. If this is so, then finding ways of enhancing reprocessing of these images could be of therapeutic value. Imagery Rescripting (ImRs) targets aversive traumatic memories and has been investigated across a range of disorders in which intrusive images are present. Wild, Hackmann, and Clark (2007) found that when ImRs was used to update the meanings of aversive memories in participants with social phobia, a resulting change was seen in their maladaptive beliefs, and in the associated intrusive images thought to play a role in maintaining the disorder. A reduction in the overall severity of the participant's social phobia was also found. Nilsson, Lundh, and Viborg (2012) also found similar changes for ImRs in social phobia without the need for cognitive restructuring. ImRs has also shown promising results as an intervention for depression (Brewin et al., 2009), and as an adjunct to treatment of personality disorders (Weeterman & Arntz, 2007) and within schema therapy (Arntz & Van Genderen, 2009). Arntz (2012) provides a comprehensive summary of the use of ImRs across disorders as well as suggesting a research agenda for developing the work within the field both in terms of clinical application and in investigating the underlying mechanisms of change. He highlights the need to investigate ImRs as a stand-alone intervention even if it is not intended for use in isolation from other treatments. Furthermore, he emphasizes the need to allow for adequate follow-up data without further intervention, to establish the possible long-term effects of ImRs in isolation. This study aims to follow that model and investigate the efficacy of ImRs as a standalone intervention for OCD, where intrusive images linked to aversive memories are also present. The current study also builds on previous case series in other disorders by incorporating a control intervention and randomization to the start of the control intervention. It was hypothesized that addressing aversive memories using ImRs would lead to a reduction in OCD symptoms, measured here by on the Yale-Brown Obsessive Compulsive Scale (Goodman et al., 1989).

Table 1 provides a brief a clinical summary of each participant with the main outcome scores. There were 7 males and 5 females and the mean age was 40. All but one of the participants had a previous trial of CBT, but none were within 12 months. The quality of the previous CBT was only possible to verify in one participant, who had CBT at our own service. The shortest trial was reported as 8 sessions and the longest as up to a year. Some reported no benefit from previous CBT and others had significant benefit. Table 2 provides a summary of the clinical imagery and memory rescripted in each participant. The ‘OCD Threat Interpretation’ refers to the meaning of the intrusion, for example participant 7 experienced intrusive thoughts and images about causing accidents whilst driving, thoughts about burning her house and concerns about contracting HIV, her interpretation of all these intrusions was that these events would come to pass and she “will cause harm and be shamed”. The mean “age of onset” was 15.1 and refers to the age when OCD was a significant problem and according to retrospective self-report met criteria for diagnosis. The mean age in the ImRs 11.6 and refers to the participant's age at the time of the events in the memory. The “Memory Rescripted” is a brief description of the content of the memory targeted by the ImRs session. The “Meaning of Memory” refers to the dominant emotion and meaning of the memory prior to the ImRs session. ‘New Meaning after ImRs’ refers to a brief summary of the updated and less negative meaning of the memory targeted in the ImRs session (Table 3). Table 2. Memory rescripted in participants. P OCD threat interpretation Age of OCD onset Memory rescripted Meaning of memory Age in ImRs New meaning after ImRs 1 Image of dead child in road interpreted as “I will cause an accident” 14 Rejection by girls in park leading to bullying Shame “I am inadequate 14 “You are as worthwhile as others” 2 Unacceptable image of black penis and thoughts“I could be gay or a predator” 7 Black boy in school uniform on a beach with whites feeling different to others Shame“I am different to others” 5 “It is the environment that is unhealthy not you” 3 Unacceptable images and thoughts of naked child “I will harm children” 13 In the biology classroom being taught about sexual predators and disapproving teacher's face Shame “I am unacceptable” 15 “You feel worried about your sexuality because of homophobia – not because you are a predator” 4 Unacceptable thoughts of naked child “I will sexually abuse my daughters and be damned by God” 23 Parental discord Incestuous acts (not intercourse) as a 12 year with 13 year old sister Shame “I am bad and will be damned” 11 “I was a child and knew no better – my person is not defined by this” 5 Unacceptable thoughts of sex with young child “I will/have harmed children and will be alone and hated” 11 Bullying whilst trapped at boarding school from peers/staff Shame, loneliness “I am alone and hated” 7 “This was not a suitable environment for a child rather than a reflection on me” 6 Unacceptable thoughts of boiling children's body parts “I am a bad mother and will harm my children violently and lose them” 29 G.P. misdiagnosing intrusive thoughts as dangerous and calling social services Shame “I am a danger and am going to lose my children” 29 “This is OCD and these are just meaningless intrusive thoughts” 7 Thoughts of being responsible for harm (e.g. HIV, accidents) “I will cause harm and be shamed” 11 Being called out in front of class and teacher kissing hand and being told by a friend to wash her hands Humiliation 8 “That is wrong and no fault of mine” 8 Responsible for harm in father “I will be responsible for my father suffering in agony for eternity” 12 Conflicts between parents – mother's furious berating of father and threatening suicide Sadness, guilt “I am responsible for resolving the pain” 6 “It is not my responsibility to heal this situation” 9 Images of mother's funeral Contamination from HIV “I will die from HIV and leave my children alone” 20 Mother's sudden death coupled with father rejecting her for new relationship Hurt I will be abandoned 18 “My mother loved me and I am connected to others” 10 Unacceptable thoughts/images of being the worst possible person alive “I am the worst kind of human being and don't deserve to live” 7 Ritualistic physical and sexual abuse at the hands of both parents/brother and wider network Shame “I am worthless and to blame for this” 6 “None of this is my fault, they are despicable human beings”/Taken out of situation and cared for 11 Unacceptable thoughts “I am racist – unlovable and will be rejected and alone” 18 Arguments between parents/rejection by father Hurt “I am unlovable” 5 “My father left because of his problems and did love us” 12 Mental contamination “Things will be tarnished and ruined forever and it will be my fault” 16 Return from school trip to the news that favorite teacher had died suddenly in context of being ashamed of kissing and fondling another teenager Sadness “Things will never be the same again” 16 Said goodbye to teacher. “I can cope with change and moving on” Table options Table 3. Summary of outcomes for 12 participants. Baseline Mean (SD) Post control Mean (SD) Post ImRs Mean (SD) 3 month follow up Mean (SD) Effect size (d) post control to 3 month fu YBOCS 24.8 (7.3) 24.1 (7.3) 16.0 (8.3) 10.7 (6.8) 1.9 OCI 57.0 (25.0) 52.7 (26.3) 41.3 (23.0) 34.1 (21.5) 0.8 RIQ 1077.1 (377.5) 1009.6 (337.6) 856.1 (410.2) 687.9 (361.1) 0.9 BAI 21.3 (13.6) 18.5 (10.7) 14.3 (11.2) 11.3 (10.5) 0.7 BDI 22.6 (11.7) 19.8 (10.0) 16.8 (9.5) 15.4 (10.9) 0.4