هنگامی که زمان حال گذشته را ملاقات می کند: به روز رسانی خاطرات آسیب زا در هراس اجتماعی

Research suggests that distorted images of the self are common in social phobia and play a role in maintaining the disorder. The images are often linked in thematic and sensory detail to distressing memories that are clustered around the onset or worsening of the disorder. This has led to speculation about the likely benefit of working directly with these memories to improve symptoms of social phobia. In this exploratory study, we describe a process of cognitive restructuring followed by imagery rescripting to update the meanings of distressing memories and images in social phobia. We first present illustrative clinical examples and then data of 14 patients with social phobia, on whom we developed this approach. Patients attended an imagery rescripting session in which a semi-structured interview was used to identify their recurrent images, the associated memories and their meanings. Next the identified memory was evoked and elaborated. We updated the meaning of the memory by first using cognitive restructuring to arrive at new perspectives and then linking these perspectives with the memory using imagery techniques. The procedure resulted in significant within session change in beliefs, and in image and memory distress and vividness. One week later significant change was seen in social phobia cognitions and a self-report measure of social anxiety. Rescripting distressing memories in social phobia appears to be an effective way of modifying maladaptive beliefs linked to recurrent negative imagery. This paper presents our exploratory investigation of how to work with the memories and encourages more rigorous investigation in this area.

At the heart of cognitive models of anxiety lies the idea that distorted appraisals lead to perceived threat and anxiety. These appraisals are typically described as verbal thoughts. To access highly charged appraisals, Beck (1976) stressed the importance of considering images and memories as well as verbal thoughts. In their manual on cognitive therapy for anxiety disorders, Beck, Emery, and Greenberg (1985) also note that in addition to affect and increased estimates of danger, imagery spontaneously emerges when approaching or entering a feared situation, further highlighting its relevance to anxiety. These observations are consistent with recent research on social phobia. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) describes social phobia as a persistent fear of certain social or performance situations, in which the person fears that they will act in a way (or show anxiety symptoms) that will be embarrassing or humiliating. A key suggestion in the Clark and Wells (1995) cognitive model of social phobia is that when feeling threatened in social situations, patients switch to processing the self as a social object, their attention turning to internal rather than external stimuli. Consistent with this view, a number of studies have found when patients with social phobia enter social situations, or recall such situations, they experience visual and/or somatic images of themselves as an object of the scrutiny of others. They report seeing themselves as if from an observer's perspective and appearing the way they imagine they come across to other people (Coles, Turk, & Heimberg, 2002; Coles, Turk, Heimberg, & Fresco, 2001; Hackmann, Surawy, and Clark, 1998; Wells, Clark, & Ahmad, 1998). They report appraising this mental representation as mirroring a true reflection of the self, yet the image or impression is typically distorted in a negative way. Many studies (Alden & Wallace, 1995; Mulkens, de Jong, Dobbelaar, & Bogels, 1999; Rapee & Abbott, 2006; Rapee & Lim, 1992; Stopa & Clark, 1993) have shown that patients hold excessively negative self-perceptions: relative to observers, they underestimate their social performance, overestimate how visible their anxiety symptoms appear and underestimate their general attractiveness. Rapee and Heimberg (1997) also suggest that on entering a social situation a socially phobic person forms a mental representation of their appearance and behaviour (as presumably seen by an audience) and simultaneously focuses attention onto both this internal representation and on any perceived threat in the environment. The mental representation is considered to be a loose amalgam based on a variety of inputs, including material from long term memory. The Clark and Wells (1995) and Rapee and Heimberg (1997) models of social phobia incorporate patients’ attention to negative self-images. It is difficult to establish the exact sequence of appraisals, imagery and attentional deployment in anxiety-provoking situations as events unfold so quickly in response to perceived danger. However, research suggests that negative self-images may have a causal role in social anxiety. Hirsch, Clark, Mathews, and Williams (2003) asked patients with social phobia to hold a negative or neutral image in mind whilst having a conversation with a stranger. The conversation was videotaped and an independent assessor watched the video to rate patients’ performance. Patients felt more anxious and believed they came across more poorly when they held the negative image in mind compared to when they held the neutral image in mind. Further, the independent assessor's ratings of patients’ performance were lower in the negative image condition. These findings have been replicated with non-clinical participants who are high in social anxiety (e.g., Hirsch, Meynen, & Clark, 2004; Vassilopoulos, 2005) and in participants who are low in public speaking anxiety (Hirsch, Mathews, Clark, Williams, & Morrison, 2006). Overall, the results suggest that deliberately holding a negative image in mind (rather than a positive or more neutral image) makes participants feel more anxious, engage in more safety behaviours, believe they come across more poorly and receive poorer performance ratings by an observer. Future studies could more closely examine whether it is only negative self-images that have these effects, or whether any anxiety provoking control image might be equally detrimental. However, the results so far suggest that negative self-images are prevalent, and play a role in maintaining social phobia. They trigger anxiety and safety behaviours, both of which can play their part in perpetuating underlying negative appraisals of social situations. There is also some evidence that the negative self-images reported in social phobia may have input from autobiographical memory. Hackmann, Clark, and McManus (2000) carried out a study of images and their possible links to memories in this disorder. All participants reported negative, spontaneous self-imagery that was recurrent. That is, the images were relatively stable across time and in feared social situations. In addition, most recurrent images were linked to memories of adverse social events, clustered in time around the onset or worsening of the disorder. These events typically involved bullying, criticism or humiliation. The links between patients’ current imagery and earlier events were established by evoking the recurrent image, exploring its content and meaning, then enquiring when in their life the patient could remember having had a similar experience. The study suggested that the intrusive images that are characteristic of social phobia may have substantial input from events in memory, since the reported images and memories were often strikingly similar in content and meaning. Further, patients frequently described the memories as representing points at which their social phobia started or worsened. Conway, Meares, and Standart (2004) suggest that memories of negative, self defining moments can be aversive, leading to avoidance, with little opportunity for these memories to find a place in autobiographical memory. This makes them more likely to be triggered automatically with the potential to disrupt functioning. They may then be described as intrusions that are “out of context, out of proportion, or simply out of time” (Rachman, 1980). Since such imagery appears to contain input from memory of upsetting experiences, we have previously speculated on the potential value of working directly with such memories in cognitive therapy for anxiety disorders (Hackmann, 2005). Intrusive imagery with input from memory of a traumatic event is an important focus in cognitive therapy for posttraumatic stress disorder (PTSD), for example. In the Ehlers and Clark (2000) approach to PTSD, attention is paid to deliberately access the meanings of the worst moments of the trauma through the process of reliving, and then updating these meanings with information that provides more realistic (e.g., “I did not die”) and less toxic (e.g., “It was not my fault”) appraisals of the trauma. This is accomplished using verbal and imagery techniques (Ehlers, Clark, Hackmann, McManus, & Fennell, 2005). During cognitive therapy for PTSD that involves these elements, the intrusive imagery decreases in frequency, distress and vividness (Ehlers, Hackmann, & Michael, 2004; Hackmann, Ehlers, Speckens, & Clark, 2004) and idiosyncratic belief ratings change. These results, and other observations across disorders, lead to the idea that where there is recurrent, intrusive imagery, there may be input from past experience, and furthermore, it may be productive to work directly on disturbing memories using similar techniques to those used in the treatment of PTSD. These suggestions are not entirely novel. Throughout the history of cognitive behavioural therapy (CBT), value has been placed on the element of imaginal exposure, giving attention to images which appear to reflect input from memory. We see this, for example, in systematic desensitisation (Weitzman, 1967), imaginal flooding (Levis, 1980) and repeated reliving or imaginal exposure (Foa & Rothbaum, 1998). In addition, procedures for addressing and transforming the content or meaning of upsetting memories have been described by many (e.g., Arntz & Weertman, 1999; Beck et al., 1985; Beck, 1995; Edwards, 1990; Giesen-Bloo et al., 2006; Hackmann (1998) and Hackmann (2005); Layden, Newman, Freeman, & Morse, 1993; Young, Klosko, & Weishhaar, 2003). However, there is a relatively limited amount of information concerning the outcome of this set of therapeutic procedures studied in isolation from other treatment components. Smucker and Neiderdee (1995) report on the therapeutic effect of imagery rescripting in PTSD arising from childhood sexual abuse. A study by Hunt et al. (2006) on participants fearful of snakes found that treatment condition (cognitive imagery modification, in-vivo exposure, or minimal exposure plus relaxation) interacted with initial severity. Specifically, highly fearful participants responded better to cognitive imagery modification than to in-vivo exposure, and they found the intervention less aversive. Both the active treatment groups improved significantly more than the group provided with a minimal exposure, relaxation control procedure. Also, delivered in a single session, imagery rescripting has produced significantly greater change than verbal discussion in bulimia nervosa (Cooper, Todd, & Turner, in press, 2007; Ohanian, 2001). Grunert, Smucker, Weis, and Rusch (2003) have reported finding imagery rescripting an effective extra component in the treatment of PTSD in cases where imaginal exposure alone has not proved effective. This Special Issue is timely as it brings together recent attempts to gather more information about the effectiveness of this type of intervention. Wheatley, Brewin, Patel, and Hackmann (this issue) describe two cases of patients with depression and intrusive memories where they obtained good results from sessions devoted exclusively to rescripting disturbing memories, and the benefits were maintained at 6 month follow-up. Arntz, Tiesema, and Kindt (this issue) present a comparison of imaginal exposure with and without imagery rescripting in the treatment of PTSD to begin the process of examining the efficacy of various elements in the treatment of disturbing memories. Other recent studies also point to the usefulness of imagery rescripting. Weertman and Arntz (in press) report the results of a comparison of imagery rescripting of disturbing memories with more standard schema change techniques in personality disorder. They found that both types of intervention led to significant change. For patients and therapists, the preferred order involved working with the memories, then moving to more present-focused work. In another study of social phobia, Wild, Hackmann, and Clark (in press) compared a single session of imagery rescripting to a control session in which the memories were only discussed. The imagery rescripting session led to significantly greater reductions in social anxiety than the control session. When we carried out the study reported here, there had been no previous studies on the effects of rescripting distressing memories on cognitions and behaviours specific to social phobia. However, we had used imagery rescripting with a subset of individuals in a recent randomised controlled trial of cognitive therapy for social phobia (Clark et al., 2006) and had the impression that it had been useful. The time seemed right to examine its effects (when delivered in a single session) on social phobia cognitions and behaviours. This paper allows us the opportunity to describe our procedure in detail, and present case material to illustrate the technique and its impact. Our procedure is unusual in that it involves an element of verbally challenging old appraisals and considering new ones, before consolidating the new perspectives in imagery. In this way it is similar to the Ehlers et al. (2005) approach to PTSD, which interweaves verbal and imagery techniques. Encouraged by the speed and magnitude of the changes in this small, exploratory study we have subsequently put our version of rescripting to a more rigorous test by comparing it to a control session of simply exploring the memories (Wild et al., in press). This has led to promising results with the imagery rescripting session demonstrating significantly greater improvement in social anxiety than the control session.