برنامه نویسی مجدد تصویرسازی به عنوان درمان مستقل برای اختلال استرس پس از سانحه مرتبط با سوء استفاده در دوران کودکی

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.

Exposure to childhood sexual and/or physical abuse (CA) is strongly associated with the occurrence of mental disorders throughout the course of life (Gilbert et al., 2009). Adults with a past of CA are three times more likely to have contact with mental health services than the general population. The highest odds ratios (OR) for DSM-IV Axis I and Axis II disorders are found for posttraumatic stress disorder (PTSD; OR = 5.56), alcohol abuse (OR = 5.88), drug abuse (OR = 5.94) and borderline personality disorder (OR = 6.07) (Cutajar, et al., 2010). This shows that CA-related trauma often results in complex presentations of severe psychopathology. Trauma-focused cognitive-behavioral therapies, particularly those including prolonged exposure (PE), have been shown to be successful in the treatment of PTSD (Bisson et al., 2007; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). While these treatments have been extensively studied among samples with PTSD following single trauma in adulthood, empirical evidence for the applicability and efficacy of these treatments in a population with CA-related PTSD is lagging behind (Cloitre, 2009). In addition, despite endorsement by professional guidelines, clinicians are often hesitant to use exposure therapy in this population due to concerns of alleged problems patients may have in managing emotions arising from trauma processing and subsequent adverse effects of PE (van Minnen, Hendriks, & Olff, 2010; van Minnen, Harned, Zoellner, & Mills, 2012). Some clinicians are more inclined to use stabilizing treatments (e.g. Dorrepaal et al., 2013), while the debate on the efficacy of such interventions is ongoing (de Jongh & Ten Broeke, 2014). Until now, it remains unknown whether the concerns about how well patients with PTSD due to CA tolerate exposure-based interventions are justified. To our knowledge, there are only two published studies, in which PE was systematically tested in samples with CA-related PTSD (Cloitre et al., 2010; McDonagh et al., 2005). In both studies intent-to treat analyses showed effect sizes for PE that are comparable to the effect sizes reported for single- and mixed-trauma samples (Bradley, Greene, Russ, Dutra, & Westen, 2005). On the other hand, in both studies PE appeared to be associated with significantly higher dropout-rates (39% resp. 41%) in comparison with active control conditions (ranging from 9%-26%; Cloitre et al., 2010; McDonagh et al., 2005). This indicates that PE may be too aversive for a considerable proportion of patients with CA-related PTSD. Two factors are proposed to cause the high dropout rates. First, direct comparisons between survivors of chronic childhood interpersonal trauma vs. those of adult-onset trauma revealed that the former group has a higher probability to experience problems in the domains of affect modulation, anger management, self-concept, and interpersonal functioning (Cloitre, Scarvalone, & Difede, 1997; Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013). This might indicate that a considerable proportion of patients with childhood abuse-related PTSD are lacking skills to effectively handle the emotions that are triggered by PE sessions. Second, some authors criticize that PE limits itself to the extinction of fear, and does not cover other emotions and cognitions often associated with CA-related PTSD, such as anger, irrational guilt, shame, disgust and self-contempt (Grunert, Weis, Smucker, & Christianson, 2007; Jung & Steil, 2013). Indeed, there is preliminary evidence that PE is less effective in changing trauma-related emotions of anger (Foa, Riggs, Massie, & Yarczower, 1995), guilt and shame (Arntz, Tiesema, & Kindt, 2007; Grunert et al., 2007). Because of these shortcomings, there have been calls for the adaptation of the existing treatment protocols for patients with CA-related PTSD. One option that has been put forward is a phase-based approach starting with a phase of ‘stabilization’, in which emotion-regulation and interpersonal difficulties are targeted prior to the application of PE (e.g. Cloitre, Cohen, & Koenen, 2006). Another approach is to modify existing trauma-focused components in such a way that they not only reduce fear responses but also deal with trauma-related cognitions and schemas. Recently, the use of Imagery Rescripting (ImRs) has attracted growing attention as a technique that targets the meanings and schemas resulting from traumatic childhood memories (Arntz, 2012). In ImRs, the patient imagines the (onset of a) traumatic experience and subsequently changes the original course of events by imagining different interventions and outcomes, thereby allowing for the change of original schematic representations and cognitions (Arntz, 2012; Hackmann, 2011). Smucker and colleagues were the first to develop a systematic approach to the use of ImRs with survivors of CA-related PTSD (Smucker & Niederee, 1995; Smucker & Dancu, 1999). In their protocol, ImRs was applied as an add-on to standard PE, based on the assumption that it would be ineffective to avoid exposure to the complete trauma memory. Until now, this protocol has not systematically been tested in a population with CA-related PTSD, but ImRs has been shown to improve standard exposure therapy (Arntz et al., 2007; Jung & Steil, 2013; Steil, Jung, & Stangier, 2011), and also to be effective in a sample with previous treatment failures (Grunert, Smucker, Weis, & Rusch, 2003). In addition, ImRs has been found to be effective in targeting intrusive images and memories within other disorders, such as social phobia (Wild, Hackmann, & Clark, 2007; Wild, Hackmann, & Clark, 2008), specific phobia (Hunt & Fenton, 2007), and depression (Wheatly et al., 2007; Brewin et al., 2009). Arntz and Weertman (1999) adapted the Smucker protocol for the treatment of traumatic childhood memories, using a three-phase ImRs-procedure. This procedure differs from the Smucker protocol in two ways. First, reliving of the memory is only used up to the moment when the patient realizes that something terrible is going to happen; from that point on, rescripting commences. In that way, patients do not have to remember all the horrid details of the trauma and the accompanying feelings of helplessness, shame and guilt. Second, in the third phase the new course of events is viewed from the child’s perspective, rather than the adult’s, eliciting different emotions stemming from the developmental level at which the trauma occurred. A recent case series has shown a good effectiveness of ImRs for refugees with war-related PTSD (Arntz, Sofi, & van Breukelen, 2013). ImRs has also been found to be effective in the treatment of borderline personality disorder (Weertman & Arntz, 2007). However, ImRs has not been investigated in a population with CA-related PTSD, yet. The aim of this pilot study is to investigate the feasibility and explore the efficacy of the treatment protocol as described by Arntz and Weertman (1999) for patients with CA-related PTSD. To achieve this we conducted a cases series in an outpatient setting.

At pre-treatment the mean score on the DERS was 107 (SD = 17.2) and on the IIP 57.3 (SD = 9.9). Fig.1 shows the individual CAPS- and IES-scores of the eight participants at pre- and post-treatment and at 3-month follow-up. Visual inspection suggests a decrease in PTSD symptoms in all participants but one (Participant 4).