نوشتن مجدد خاطرات اولیه در هراس اجتماعی مرتبط با تصاویر منفی: یک مطالعه مقدماتی

Negative self-images are a maintaining factor in social phobia. A retrospective study (Hackmann, A., Clark, D.M., McManus, F. (2000). Recurrent images and early memories in social phobia. Behaviour Research and Therapy, 38, 601–610) suggested that the images may be linked to early memories of unpleasant social experiences. This preliminary study assessed the therapeutic impact of rescripting such memories. Patients with social phobia (N = 11) attended 2 sessions, 1 week apart. The first was a control session in which their images and memories were discussed but not modified. The second was an experimental session in which cognitive restructuring followed by an imagery with rescripting procedure was used to contextualize and update the memories. No change was observed after the control session. The experimental session led to significant improvement in negative beliefs, image and memory distress and vividness, fear of negative evaluation, and anxiety in feared social situations. The results suggest that rescripting unpleasant memories linked to negative self-images may be a useful adjunct in the treatment of social phobia.

Individuals with social phobia often report experiencing negative, distorted images when in social situations. In their negative images they tend to see their worst fears being realized. Individuals with a fear of blushing, for example, may have images in which their face predominates and appears much larger and more flushed than it actually is. Clinically, such images appear to be problematic for a number of reasons. First, patients often believe that their negative images are an accurate reflection of how they appear to other people. They therefore think they come across much worse than they actually do, which tends to maintain their social anxiety. Second, the negative self-images seem to motivate patients to use self-protective strategies (safety behaviors) that are themselves problematic, such as covering one’s face to hide a blush or answering questions with one-word answers to avoid saying the wrong thing. Such behaviors prevent patients from disconfirming their fears (Salkovskis, 1991) and may also have the consequence of contaminating the social interaction by making patients appear unfriendly and aloof (Clark and Wells, 1995 and Rapee and Heimberg, 1997). One of the first empirical studies of imagery in social phobia was conducted by Hackmann, Surawy, and Clark (1998). Patients with social phobia and nonpatient controls were asked to recall a recent social situation in which they had felt anxious. They were then asked about any spontaneous imagery that may have occurred at the time. Almost all patients with social phobia reported experiencing negative images of themselves from the observer perspective. From this perspective, they saw their worst fears happening as if viewed from the outside. They also believed their images to be true at the time. Nonpatients were significantly less likely to report observer perspective images and, in addition, their images were less negative. In a subsequent study, Hackmann et al. (2000) used a structured interview that aimed to further explore the nature of patients’ spontaneous images. All patients with social phobia reported that their negative, observer perspective images were recurrent in the sense that they tended to occur in different social situations. In addition, the images were linked in meaning and content to earlier unpleasant social events that occurred around the onset of the disorder. The images appeared to be extracted essences of memories of being criticized, humiliated, bullied, or experiencing other adverse social events. The authors hypothesized that early unpleasant memories lead patients to develop negative images of how they think they come across to others and these images are reactivated in subsequent social situations. Because the images are similar in content across social situations, it is suggested that they are not being updated in light of later, more benign experiences. This may be partly a consequence of excessive self-focus in social situations (Clark and Wells, 1995 and Rapee and Heimberg, 1997). Using a slightly different paradigm, four other studies (Coles et al., 2002, Coles et al., 2001, Wells et al., 1998 and Wells and Papageorgiou, 1999) have investigated the perspective that patients with social phobia report taking when recalling social situations. Consistent with Hackmann et al.’s (1998) findings for spontaneous imagery, all four studies found that patients with social phobia were more likely than controls to take an observer perspective when recalling social events. This effect was largely confined to memories of social events (Wells et al., 1998), was more marked with high-anxiety events (Coles, Turk, et al., 2001), and became more marked as time since the event increased (Coles et al., 2002). To date, three studies have experimentally manipulated negative self-imagery in individuals with social phobia or high social anxiety in order to determine whether it has a role in maintaining the disorder. All reported positive results. Hirsch, Clark, Mathews, and Williams (2003) asked patients with social phobia to have a conversation with a stranger while holding in mind either their usual negative image of themselves or a less negative (control) image. The negative image led participants to feel more anxious. They also thought their symptoms were more noticeable and that they had performed more poorly when they held the negative image in mind. Further, an assessor, who did not know which image participants held in mind, rated their anxiety as more evident and their behavior as less positive in the negative imagery condition. Thus, negative self-imagery increased anxiety and undermined effective social performance. Vassilopoulos (2005) conducted a similar study with high and low socially anxious volunteers. Participants gave a speech in front of a camera. Half of each group held a negative observer perspective image during the speech, whereas the other half held a positive image of themselves. The high anxious group perceived more bodily sensations, rated specific aspects of their performance more poorly, and believed their self-image to be a more accurate reflection of how they came across when they held a negative image in mind. Hirsch, Meynen, and Clark (2004) had high socially anxious individuals have two conversations with a conversational partner. During one conversation they held a negative image in mind and during the other, they held a less negative (control) image in mind. When holding the negative image in mind, the socially anxious volunteers felt more anxious. They also reported using more safety behaviors and believed that they performed more poorly. They also overestimated how poorly they came across compared to ratings the conversational partners made. Their partners rated them as performing more poorly in the negative imagery condition. This study replicated the earlier finding that negative imagery leads patients with social phobia to feel and look more anxious. In addition, it suggested that negative images motivate patients to use safety behaviors which can, in turn, contaminate the social interaction. Recognizing the importance of negative self-images, several cognitive-behavioral treatment (CBT) programs for social phobia (for example, Clark and Wells, 1995, Clark et al., 2003, Heimberg and Becker, 2002 and Rapee and Sanderson, 1998) include techniques for correcting distorted self-images. Until recently the techniques (video feedback, surveys of other people’s observations, behavioral experiments) have all been present-focused and have not attempted to directly modify the early memories that are linked to images. However, in a recent trial of cognitive therapy for social phobia (Clark et al., 2006), an imagery with rescripting technique was used to contextualize and update early memories of unpleasant social experiences in a subset of patients whose response to the standard, present-focused techniques was relatively modest. The authors speculated that use of the technique contributed to the good overall results observed in the trial but they were unable to provide data to support this speculation as the trial did not include a separate evaluation of the technique. Imagery with rescripting techniques that focus on changing unpleasant memories have also been used as major components of CBT programs for borderline personality disorder (Giesen-Bloo et al., 2006) and for posttraumatic stress disorder arising from childhood sexual abuse (Smucker & Neiderdee, 1995). However, as with social phobia, the specific impact of the memory-focused techniques was not assessed. As far as we are aware, the only published study that has attempted to isolate the specific impact of memory work is Ohanian’s (2001) single case report. After eight sessions of present-focused CBT, a 22-year-old woman with bulimia nervosa reported a 50% reduction in symptoms. Ohanian (2001) then looked at a critical early event that was linked to the patient’s most salient beliefs. To identify it, she asked the patient to describe an event in childhood in which she had negative feelings about herself. The rationale was that beliefs about her self-worth would have originated or been reinforced during a critical period. The patient identified an event that occurred when she was 10 years old. Imagery rescripting involved having her describe it in the present tense. At the point in the memory when she felt very hurt, she was encouraged to visualize her adult self entering the room to challenge the critical parent and then offer support and nurturance to her child self. This one session of memory work was followed by an almost complete cessation of binge-purge behaviors by the 3-month follow-up. The present study was a preliminary attempt to identify whether imagery with rescripting focusing on early memories would generally be helpful in social phobia if given to an unselected group of patients in a tightly controlled fashion. It assessed the impact of rescripting early memories on negative images and the current symptoms of social phobia. We predicted that imagery with rescripting would reduce the strength of patients’ negative self-beliefs and their anxiety about feared social situations. We also anticipated a reduction in the frequency, vividness, and distress of patients’ recurrent images. By contrast, we predicted that simply exploring the memories would not be beneficial.