Introduction
Interest in and applications of imagery rescripting (ImRs) are rapidly increasing (Arntz, Reference Arntz2012; Hagennars and Holmes, Reference Hagennars and Holmes2012). ImRs is a set of therapeutic techniques addressing specific memories of earlier experiences associated with present problems (Arntz, Reference Arntz2012). In an ImRs procedure, aversive autobiographical memories are rendered less unpleasant or emotional (Slofstra et al., Reference Slofstra, Nauta, Holmes and Bockting2016). ImRs describes a set of therapeutic techniques aimed at changing these negative meanings (Stopa, Reference Stopa2011). According to a historical review on ImRs by Edwards (Reference Edwards2007), in the late 1980s and early 1990s, therapists such as Jeff Young (schema-focused therapy) and Mary-Ann Layden (personality disorder treatment) started to fully explain the application of imagery-based techniques in the framework of cognitive therapy (Young and Lindemann, Reference Young and Lindemann1992; Layden et al., Reference Layden, Newman, Freeman and Morse1993). Smucker developed an imagery-focused treatment for adult survivors of childhood sexual abuse, designed to alleviate post-traumatic stress disorder (PTSD) symptomatology and alter abuse-related beliefs and schemas (Smucker et al., Reference Smucker, Dancu, Foa and Niederee1995).
Arntz and Weertman (Reference Arntz and Weertman1999) expanded ImRs to include patients with personality disorders and attempted to address individual problems rooted elsewhere than childhood sexual abuse. Since then, the application of ImRs to many psychiatric disorders has been studied and practised: social anxiety disorder (SAD) (Wild et al., Reference Wild, Hackmann and Clark2007, Reference Wild, Hackmann and Clark2008; Wild and Clark, Reference Wild and Clark2011; Nilsson et al., Reference Nilsson, Lundh and Viborg2012; Lee and Kwon, Reference Lee and Kwon2013; Frets et al., Reference Frets, Kevenaar and Van Der Heiden2014; Reimer and Moscovitch, Reference Reimer and Moscovitch2015; Norton and Abbott, Reference Norton and Abbott2016), PTSD (Arntz et al., Reference Arntz, Tiesema and Kindt2007; Long and Quevillon, Reference Long and Quevillon2009; Hackmann, Reference Hackmann2011; Afkham and Toghchi, Reference Afkham and Toghchi2012; Arntz et al., Reference Arntz, Sofi and van Breukelen2013; Hoffart et al., Reference Hoffart, Øktedalen, Langkaas and Wampold2013; Prasko et al., Reference Prasko, Grambal, Ociskova, Kamaradova and Latalova2015; Raabe et al., Reference Raabe, Ehring, Marquenie, Olff and Kindt2015), depression (Patel et al., Reference Patel, Brewin, Wheatley, Wells, Fisher and Myers2007; Wheatley et al., Reference Wheatley, Brewin, Patel, Hackmann, Wells, Fisher and Myers2007; Brewin et al., Reference Brewin, Wheatley, Patel, Fearon, Hackmann, Wells, Fisher and Myers2009; Moritz et al., Reference Moritz, Hörmann, Schröder, Berger, Jacob, Meyer and Holmes2014), bulimia nervosa (Ohanian, Reference Ohanian2001), ophidiophobia (snake phobia) (Hunt and Fenton, Reference Hunt and Fenton2007), cancer patients with psychological distress and maladaptive adjustment derived from intrusive memories (Whitaker et al., Reference Whitaker, Brewin and Watson2010), trauma-related nightmares (Long et al. Reference Long, Davis, Springer, Elhai, Rhudy, Teng and Frueh2011a,Reference Long, Hammons, Davis, Frueh, Khan, Elhai and Tengb), pain sufferers (Philips and Samson, Reference Philips and Samson2012), psychosis patients with auditory hallucinations (Ison et al., Reference Ison, Medoro, Keen and Kuipers2014), bowel/bladder control anxiety (Pajak and Kamboj, Reference Pajak and Kamboj2014), obsessive compulsive disorder (OCD) (Veale et al., Reference Veale, Page, Woodward and Salkovskis2015), and body dysmorphic disorder (Ritter and Stangier, Reference Ritter and Stangier2016; Willson et al., Reference Willson, Veale and Freeston2016). However, our review of the literature failed to find any study on the application of ImRs to panic disorder (PD).
PD is an anxiety disorder characterized by recurring, unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least four of 13 panic symptoms occur. In the general population, the 12-month prevalence estimate for PD across the USA and several European countries is about 2–3% in adults and adolescents (American Psychiatric Association, 2013). As with many anxiety and depressive disorders, PD is often co-morbid with other psychological disorders and is associated with functional disability (e.g. social and occupational impairment; Kessler et al., Reference Kessler, Chiu, Jin, Ruscio, Shear and Walters2006). Although selective serotonin re-uptake inhibitors remain a first-line pharmacotherapy of PD (Batelaan et al., Reference Batelaan, Van Balkom and Stein2011), cognitive behavioural therapy (CBT) has been shown to be more effective than pharmacotherapy. Clark et al. (Reference Clark, Salkovskis, Hackmann, Middleton, Anastasiades and Gelder1994) compared cognitive therapy, applied relaxation, imipramine (mean 233 mg/day), or a 3-month wait followed by allocation to treatment. During treatment, patients had up to 12 sessions in the first 3 months. Imipramine was gradually withdrawn after 6 months. Comparisons between treatments showed that at 3 months, cognitive therapy was superior to both applied relaxation and imipramine on most measures. Between 6 and 15 months, several imipramine patients relapsed. At 15 months, cognitive therapy was again superior to both applied relaxation and imipramine. Furthermore, Roshanaei-Moghaddam et al. (Reference Roshanaei-Moghaddam, Pauly, Atkins, Baldwin, Stein and Roy-Byrne2011) conducted a meta-analysis comparing CBT and pharmacotherapy, with or without placebo, in adults with major depressive or anxiety disorders. The primary effect size was calculated from disorder-specific outcome measures as the difference between CBT and pharmacotherapy outcomes (i.e. positive effect size favours CBT; negative effect size favours pharmacotherapy). The authors found that effects for PD significantly favoured CBT over medications (.50, 95% CI: 0.02, 0.98).
CBT for PD has been developed based on Clark's (Reference Clark1986) cognition model of panic attacks. Clark's approach is based on the idea that panic attacks are frequently the result of misinterpreting normal bodily sensations as a sign of an impending physical or mental catastrophe (such as a heart attack or going mad) (Clark et al., Reference Clark, Salkovskis, Ost, Breitholtz, Koehler, Westling, Jeavons and Gelder1997). This misinterpretation generates a feedback effect where anxiety, physical symptoms and negative thoughts reinforce each other.
Salkovskis et al. (Reference Salkovskis, Clark, Hackmann, Wells and Gelder1999) later added the hypothesis that safety-seeking behaviours play an important role in maintaining anxiety, because they prevent patients from benefiting from a disconfirmatory experience. Therefore, many versions of CBT for PD that are currently being performed seek to identify and change mistaken beliefs about physical symptoms and their consequences. Furthermore, it is an integral part of CBT for PD to conceptualize avoidance behaviours, a maintenance factor for PD, and to confront feared stimuli and situations (American Psychiatric Association, 2009).
Intrusive images and traumatic memories of patients with PD have not yet been fully studied. Day et al. (Reference Day, Holmes and Hackmann2004) explored recurrent images in patients with agoraphobia and found that all participants with agoraphobia (but no control participants) reported experiencing distressing, recurrent imagery in agoraphobic situations. The imagery was reported as being associated with unpleasant memories of events. Wenzel et al. (Reference Wenzel, Sharp, Brown, Greenberg and Beck2006) developed the Panic Beliefs Inventory (PBI) to assess the dysfunctional attitudes and beliefs that panic patients have about specific symptoms and panic in general. An exploratory factor analysis on a large sample of panic patients revealed that the instrument was divided into four factors – Anticipatory Anxiety, Physical Catastrophes, Emotional Catastrophes, and Self-Deprecation – that were later translated into four scales that could be summed to obtain a total score, reflecting the higher order construct of maladaptive panic beliefs. Wenzel and Cochran (Reference Wenzel and Cochran2006) examined the retrieval of autobiographical memories prompted by automatic thoughts representative of maladaptive schema content specific to PD, SAD and non-anxious participants. Panic participants retrieved memories cued with panic disorder-related automatic thoughts more quickly than SAD and non-anxious participants, indicating that panic participants were characterized by general threat-relevant autobiographical memory biases. Considering these studies, PD patients may be significantly influenced by limited information from past traumatic events when processing current panic situations. Thus, in the same way that ImRs has been shown to be effective in SAD (Wild et al., Reference Wild, Hackmann and Clark2007, Reference Wild, Hackmann and Clark2008; Wild and Clark, Reference Wild and Clark2011), rescripting traumatic memory in images may result in improvement in PD patients.
There is an option to apply a PTSD protocol as per Ehlers and Clark (Reference Ehlers and Clark2000) to panic patients. Just like traumatic experiences, panic attacks are perceived as sudden, overwhelming and subjectively life-threatening events. In addition, in PD with agoraphobia, patients typically respond to a panic attack with intense fear and helplessness. This means that some of the memory characteristics in PTSD trauma memory should also characterize memory of severe panic attacks in PD of agoraphobia patients (Hagenaars et al., Reference Hagenaars, van Minnen, Hoogduin and Verbraak2009). The reason for choosing ImRs instead of a PTSD protocol in this study was that PD trauma memories had less re-experiencing elements than PTSD trauma memories (Hagenaars et al., Reference Hagenaars, van Minnen, Hoogduin and Verbraak2009). Thus, the traumatic memory of patients with PD is not as fragmented as that of patients with PTSD, and therefore does not require much elaboration. The purpose of this study was to add ImRs to conventional CBT for PD patients and to explore its effectiveness.
Method
Study design
Our study was conducted in a single-arm, uncontrolled trial of individual CBT for PD in a Japanese clinical setting (Seki et al., Reference Seki, Nagata, Shibuya, Yoshinaga, Yokoo, Ibuki, Minamitani, Kusunoki, Inada, Kawasoe and Adachi2016), registered in the National UMIN Clinical Trials Registry (ID: UMIN000022693).
Participants
Fifteen patients were enrolled through clinical referrals from specialist clinics and from the community via web-based advertisements, as described in Seki et al. (Reference Seki, Nagata, Shibuya, Yoshinaga, Yokoo, Ibuki, Minamitani, Kusunoki, Inada, Kawasoe and Adachi2016). We predicted a need for 15 participants, assuming that eight therapists were responsible for an average of 2.5 participants who were enrolled during the registration period (April 2014 to July 2016), and three-quarters of participants would withdraw; however, in this study, we excluded three patients, as they had not received an ImRs session, or there was a lack of available data concerning ImRs for these patients. Apart from that, we added three new patients via the same route within the study period. Ultimately, 15 patients were enrolled. Written, informed consent was obtained from all patients.
We used the following inclusion criteria: primary diagnosis of PD according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria, aged between 18 and 65 years with at least moderately severe PD [a Panic Disorder Severity Scale (PDSS) score ≥ 8; Houck et al., Reference Houck, Spiegel, Shear and Rucci2002]. Co-morbid diagnoses were permitted if they were clearly secondary (i.e. the PD symptoms were both the most severe and the most impairing).
Exclusion criteria were as follows: psychosis, pervasive developmental disorders/mental retardation, a current high risk of suicide, substance abuse or dependence in the past 12 months, or anti-social personality disorder. All patients were evaluated by a psychiatrist using the Mini-International Neuropsychiatric Interview (Sheehan et al., Reference Sheehan, Lecrubier, Sheehan, Amorim, Janavs, Weiller, Hergueta, Baker and Dunbar1998; Otsubo et al., Reference Otsubo, Tanaka, Koda, Shinoda, Sano, Tanaka, Hiroshi, Masaru and Kamijima2005). Therapists and chart review confirmed treatment history. Participants’ characteristics are shown in Table 1.
Table 1. Participants’ baseline demographic and clinical characteristics (N = 15)
SD, standard deviation; PD, panic disorder; IQR, interquartile range; PDSS, Panic Disorder Severity Scale.
Treatment
Individual CBT was conducted in 16, 50-minute, weekly sessions. We developed our CBT program for PD to focus on changing catastrophic misinterpretations of bodily sensations, as per the Clark et al. model (Reference Clark, Salkovskis, Ost, Breitholtz, Koehler, Westling, Jeavons and Gelder1997). We also applied several concepts from the Clark and Wells model for SAD (Reference Clark and Wells1995). We added the concept of the detrimental effects of safety behaviours, attentional bias modification (attentional shift training), behavioural experiments including interoceptive exposure (systematic exposure to body sensations), ImRs, and reconsideration of worry/rumination to strengthen anticipatory anxiety.
The main treatment steps were as follows:
(a) Assessment
(b) Psychoeducation
(c) Case conceptualization
(d) Role play experiment with or without safety behaviour
(e) Cognitive reconstruction of catastrophic body sensation image
(f) Attention shift training
(g) Behavioural experiment
(h) ImRs of traumatic memories
(i) Modifying problematic pre- and post-event processing
(j) Comparison of belief in oneself and others for the worst situation (surveys of other people's observations)
(k) Schema work
(l) Relapse prevention
(m) Termination
The rationales for the application of some concepts from the SAD model to PD treatment are shown below:
Attention shift training
Attention shift training in this study was intended to direct participants’ attention away from internal sensations. The effectiveness of attention training on patients with PD has been suggested by Wells (Reference Wells1990) and Wells et al. (Reference Wells, White and Carter1997). Wells (Reference Wells1990) reported a case of relaxation-induced anxiety in a patient with PD. He reported the use of an attention training procedure, which was effective in eliminating panic and facilitated tension reduction without producing anxiety. Wells et al. (Reference Wells, White and Carter1997) investigated the effects of attention training on panic frequency, general anxiety, and beliefs across two PD cases and one SAD case, and the results were consistent with those of a previous study (Wells, Reference Wells1990) and provided preliminary evidence that panic attacks, anxiety and negative beliefs can be effectively and lastingly reduced through cognitive techniques that do not directly target the content of negative appraisal.
Reconsideration of worry/rumination
Reconsideration of worry/rumination in this study was intended to examine the advantages and disadvantages of post-event processing (PEP). Research on PEP, where individuals conduct a post-mortem evaluation of a social situation, has focused primarily on its relationship with SAD. Laposa et al. (Reference Laposa, Collimore and Rector2014) examined the relationship between PEP and disorder-specific symptom severity for SAD, OCD, PD and generalized anxiety disorder (GAD). PEP ratings were found to be associated with disorder-specific symptom severity in SAD, GAD and PD, but not in OCD. The results showed that PEP might be a transdiagnostic process with relevance to a broad range of anxiety disorders, not just SAD.
The ImRs procedure in this study was based on the application of ImRs to SAD by Clark and colleagues (Wild et al., Reference Wild, Hackmann and Clark2008; Wild and Clark, Reference Wild and Clark2011). Based on three randomized controlled trials confirming the effectiveness of a cognitive therapy (CT) program and suggesting that a group format may not be advantageous (Clark et al,. Reference Clark, Ehlers, McManus, Hackmann, Fennell, Campbell, Flower, Davenport and Louis2003; Stangier et al., Reference Stangier, Heidenreich, Peitz, Lauterbach and Clark2003; Mortberg et al., Reference Mortberg, Clark, Sundin and Wistedt2007), Clark et al. (Reference Clark, Ehlers, Hackmann, McManus, Fennell, Grey, Waddington and Wild2006) compared CT with exposure plus applied relaxation (EXP+AR), or wait-list (WAIT). CT and EXP+AR were superior to WAIT on all measures and CT led to greater improvement than EXP+AR. Percentages of patients who no longer met diagnostic criteria for social phobia at post-treatment–wait were as follows: 84% in CT, 42% in EXP+AR and 0% in WAIT. At the 1-year follow-up, differences in outcomes persisted. Wild et al. (Reference Wild, Hackmann and Clark2007, Reference Wild, Hackmann and Clark2008) conducted two studies to assess the effects of ImRs alone in unselected populations of patients with SAD. The authors’ ImRs protocol was broadly based on Arntz and Weertman's adaptation of the Smucker protocol (Arntz and Weertman, Reference Arntz and Weertman1999; Smucker et al., Reference Smucker, Dancu, Foa and Niederee1995). Wild et al. (Reference Wild, Hackmann and Clark2007) reported pre- and post-rescripting results in 14 patients with SAD. The results showed that ImRs alone was associated with significant improvements in patients’ negative social beliefs, the vividness and distress of their image and early memory, and in self-reported measures of social anxiety. Wild et al. (Reference Wild, Hackmann and Clark2008) then compared a session of ImRs with a control session in which images and memories were explored without being updated. The result showed that the ImRs session was associated with significantly greater improvement in negative beliefs; image, memory distress, and vividness; fear of negative evaluation; and anxiety in feared social situations. Subsequently, Wild and Clark (Reference Wild and Clark2011) described the importance of updating negative imagery in SAD, which is the theoretical basis for SAD.
As already mentioned, our ImRs protocol was based on Wild et al. (Reference Wild, Hackmann and Clark2008) and Wild and Clark (Reference Wild and Clark2011). The procedure by Wild et al. was broadly based on Arntz and Weertman's adaptation of the Smucker protocol (Arntz and Weertman, Reference Arntz and Weertman1999; Smucker et al., Reference Smucker, Dancu, Foa and Niederee1995). The ImRs procedure in this study was as follows:
Identifying the recurrent image, the linked memory and the encapsulated belief
A semi-structured interview, based on Hackmann et al. (Reference Hackmann, Clark and McManus2000), was conducted for patients to identify recurrent images in panic situations, along with an early traumatic memory linked to the image. First, the patients were asked to recall and describe an image that appeared repeatedly in panic situations. Then, they were asked to rate the vividness and distress of the image. Following this, patients were asked what the image meant to them, answering these questions: ‘What is the worst thing about the image?’ and ‘What does it mean about you as a person?’. Patients were then asked when they first remembered feeling the way they did in their image and to describe the events associated with that feeling. The patients were also asked what the early traumatic memory meant to them, answering similar questions. The patients were asked to rate the vividness and distress of the memory. Subsequently, the patients were asked to summarize the meaning of the image and the memory in one or two sentences (i.e. encapsulated belief). Lastly, they were asked to rate the degree of conviction of their encapsulated belief.
Phase 1: Cognitive restructuring
The therapists initiated the patients into a cognitive restructuring of their encapsulated belief by establishing a new perspective on their early traumatic memory. The patients were encouraged to examine the validity of their encapsulated belief by listing incongruent evidence. They were also encouraged to remember the results of behavioural experiments performed in previous CBT sessions. Through this process, the patients came to view an early traumatic memory in a more balanced way and understood that the memory was a time-limited experience without extensive implications for the present and the future.
Phase 2: Imagery rescripting
The therapists then initiated the patients into an imagery rescripting phase, which consisted of three stages:
Stage 1: The patients were asked to return to the age when they experienced the traumatic memory for the first time. They were asked to relive their memory as if the event was taking place here and now and to describe the scene of the memory in the present tense.
Stage 2: The patients were asked to explain the scene from a distant perspective, as if they were observing an event that occurred to a younger self. Within stage 2, the goal was to offer some form of intervention rather than just acting as a bystander. Thus, the goal was to create mastery imagery.
Stage 3: The patients were asked to relive the memory again, but this time as if the present adult self was accompanying the younger self. The adult self was encouraged to provide a new perspective on the traumatic memory that had been gained in Phase 1 (cognitive restructuring). The adult self was also encouraged to provide advice to the younger self as they were experiencing the traumatic event. Thus, the goal of stage 3 was to develop compassionate imagery.
When all procedures were completed, patients were asked how they felt. At the end of the imagery rescripting phase, the patients were asked to rate the vividness and distress of the image and the memory, respectively. They were also asked to rate the degree of conviction of their encapsulated belief.
All sessions including ImRs were audiotaped, and participants were encouraged to listen to the recordings as part of their homework.
Quality control
The CBT was delivered by eight therapists (six clinical psychologists and two psychiatrists) who were experienced in delivering CBT for PD. To confirm all therapists’ adherence to the protocol and assist with the planning of future sessions for each treatment, all therapists attended weekly group supervision sessions with other therapists and a senior supervisor (E.S.). The senior supervisor also checked the quality of the CBT delivered by the therapists using the Cognitive Therapy Scale-Revised (Blackburn et al., Reference Blackburn, James, Milne, Baker, Standart, Garland and Reichelt2001).
Measures
(1) Outcome measure of the whole CBT
The outcome measure of our CBT program was the self-reported severity of PD, as measured by the Panic Disorder Severity Scale (PDSS) (Shear et al., Reference Shear, Rucci, Williams, Frank, Grochocinski, Vander Bilt, Houck and Wang2001). The self-report form of the PDSS (Houck et al., Reference Houck, Spiegel, Shear and Rucci2002) measures the severity of PD on a 5-point Likert-type scale ranging from 0 (not severe) to 4 (severe); higher scores indicate more severe PD. This scale was adapted from the original, clinician-administered scale (Shear et al., Reference Shear, Rucci, Williams, Frank, Grochocinski, Vander Bilt, Houck and Wang2001); it is the most frequently used scale for the assessment of PD. The interpretation of the PDSS total score (Furukawa et al., Reference Furukawa, Shear, Barlow, Gorman, Woods, Money, Etschel, Engel and Leucht2009) differed according to the presence or absence of agoraphobia. When the patients were not agoraphobic, score ranges 0–1 corresponded to ‘normal’, 2–5 with ‘borderline’, 6–9 with ‘slightly ill’, 10–13 with ‘moderately ill’, and 14 and above with ‘markedly ill’. When the patients were agoraphobic, score ranges 3–7 meant ‘borderline’, 8–10 ‘slightly ill’, 11–15 ‘moderately ill’, and 16 and above ‘markedly ill’. The Japanese version of the PDSS was developed by Katagami (Reference Katagami2007). Other measures used are shown in Seki et al. (Reference Seki, Nagata, Shibuya, Yoshinaga, Yokoo, Ibuki, Minamitani, Kusunoki, Inada, Kawasoe and Adachi2016). The PDSS (and all measurements in the study of Seki et al., Reference Seki, Nagata, Shibuya, Yoshinaga, Yokoo, Ibuki, Minamitani, Kusunoki, Inada, Kawasoe and Adachi2016) were conducted before the first session (at week 0; pre-CBT), after the eighth session (week 8; mid-CBT), and after the final session (week 16; post-CBT).
(2) ImRs ratings
Imagery and memory ratings (vividness and distress)
As described in the ImRs procedure (Wild et al., Reference Wild, Hackmann and Clark2008), patients were asked how vivid an image recurrent in panic situations was on a scale ranging from 0 (not at all) to 100 (extremely). They were also asked how distressing the image was on the same scale. The vividness and distress of the early traumatic memory linked to a recurrent image were also rated in the same way.
Encapsulated belief rating
Patients were asked to summarize the meanings of an image that was recurrent in panic situations and related early traumatic memory in one or two sentences as an encapsulated belief. They were then asked to rate how much they believed this statement to be true, on a scale ranging from 0 (not at all) to 100 (extremely). All ImRs ratings were conducted prior to and after the ImRs session.
Statistical analysis
All statistical tests were two-tailed, and an alpha level of .05 was employed. All data were analysed using SPSS for Windows version 23 (SPSS Inc., Chicago, IL, USA). The outcomes of the CBT for PD were quantified as follows. First, regarding the outcome of our entire CBT program (PDSS scores), we analysed changes between pre-CBT and the other two time points (mid-CBT and post-CBT) using repeated measures, within-subjects analyses of variance (ANOVAs). We performed a non-parametric Wilcoxon signed rank test to compare pre- and post-ImRs ratings, because they were not normally distributed. The effect size (γ=Z/√2n) was also calculated for changes in each ImRs rating (Field, Reference Field2009). According to Cohen (Cohen, Reference Cohen1992), the effect size of the correlation coefficient is categorized as follows: small (0.10–0.29), medium (0.30–0.49) and large (0.50 and above). Finally, we performed a paired t-test to determine the correlation between the value obtained by subtracting the post-PDSS score from the pre-PDSS score and the amount of change in each ImRs rating, as these data were normally distributed.
Results
The characteristics of the participants are given in Table 1.
For images repeatedly appearing in panic situations, 12 (80%) patients had images of symptoms of panic attacks, four (27%) patients had images of anticipatory anxiety, six (40%) patients had spatial images (being in a closed space, in a train, at a station, in a dark place, in a large space), and four (27%) patients had images of loneliness (being understood by no one, being alone, being in a place without acquaintances). Of note, one patient may have had multiple images.
Regarding the initial traumatic memory associated with the recurrent images, nine (60%) patients had a memory of the first panic attack, two (13%) patients had a memory of other panic attacks (one patient had a memory of a second panic attack, another of a feeling experienced as a child that was similar to the current feeling of panic attacks), and four (27%) patients had memories of events other than panic attacks (absent from school due to vomiting for weeks, seeing my mother suffering from cancer, being misunderstood by a teacher and running away from school, and being criticized by my mother at a party).
Table 2 gives details of individual patients in ImRs.
Table 2. Details of individual patients in imagery rescripting
Table 3 shows themes commonly observed in the worst meaning of images, the worst meaning of memory, and encapsulated beliefs. Self-negative contents not directly related to panic attack were observed in ImRs. Among these, the five representative themes were as follows: ‘being worthless’, ‘being helpless’, ‘being lonely’, ‘bothering others’, and ‘showing embarrassing behaviour in public’.
Table 3. Themes in the meaning of images and memories, encapsulated beliefs (N = 15)
Note: One patient may have multiple meanings and beliefs. PD, panic disorder.
Table 4 shows pre- and post-scores for ImRs ratings. ImRs significantly reduced distress from images, memories and encapsulated beliefs; however, it did not change the vividness of images and memories. The effect sizes on distress of image, distress of memory, and conviction degree of encapsulated belief were 0.55 (large), 0.43 (medium), and 0.55 (large), respectively. Although the participants in our study were partially different from those in the study of Seki et al. (Reference Seki, Nagata, Shibuya, Yoshinaga, Yokoo, Ibuki, Minamitani, Kusunoki, Inada, Kawasoe and Adachi2016), we obtained a similar result (i.e. a significant reduction in PDSS score). The mean total PDSS score decreased from 13.1±4.8 at pre-CBT to 8.2±4.7 at mid-CBT and to 6.1±5.0 at post-CBT. A repeated measures ANOVA revealed a significant main effect of time point on the PDSS total score: F (2,28) = 28.9, p < .001; however, there was no significant correlation between the value obtained by subtracting the post-PDSS score from pre-PDSS score and the change amount in each ImRs rating (data not shown). Follow-up data after 1 year were obtained from 10 of 15 patients, and the mean total PDSS score was 5.4±3.1.
Table 4. Pre- and post-ImRs ratings (N = 15)
ImRs, imagery rescripting; IQR, interquartile range; r, effect size; *p < .05, **p < .01.
Discussion
This study was the first attempt to apply ImRs to PD. We obtained the following results for images, memories, beliefs, and the effect of ImRs on patients with PD. All patients had recurrent images in panic situations. Among the images that the patients had were an image of symptoms of panic attacks, anticipatory anxiety, an image of being confined in a closed space, and an image of loneliness. The spatial image seemed related to agoraphobia; however, the loneliness images are not necessarily related to panic attacks.
The meanings of image, memory and encapsulated beliefs were idiosyncratic and patient specific, relating to individual trauma experiences. However, self-negative contents not directly related to symptoms of panic attack were observed as common themes beyond the differences of individual patients. These themes may be related to the persistence of panic symptoms by controlling patients’ thoughts and indirectly affecting emotion, behaviour and body sensation. Depression and SAD are known to often be co-morbid with PD; among the themes observed in ImRs, the self-negative contents of being worthless, being helpless and being lonely may be involved in depression. Those of bothering others and showing embarrassing behaviour in public may be seen within SAD. The process of treating such themes is not included in conventional CBT for PD. Therefore, it is considered clinically meaningful to add ImRs sessions to conventional CBT.
ImRs significantly reduced the distress of images and memories. Even though these did not lead to the creation of new functional beliefs, the confidence of maladaptive beliefs was decreased. However, it did not change the vividness of images and memories. This result suggests that the series of processes of ImRs alleviated the pain of traumatic memory and corrected the non-functional and biased beliefs derived from the memory. As these images and memories were evoked during ImRs, it is natural that the vividness of the image and the memory did not decrease after ImRs.
We assumed that the correlation between changes in PDSS scores and changes in encapsulated beliefs would reflect mechanisms of change. Contrary to our expectation, there was no significant correlation between the reduction in the severity of the PD (as measured by PDSS) over the course of the whole CBT program and the change in each ImRs rating. The CBT conducted in this study included other sessions than ImRs. While ImRs session were placed in the second half of the CBT, the change in the PDSS score was larger in the amount of change from pre- to mid-treatment than from mid- to post-treatment. Improvement at the symptomatic level of PD seems to be mostly obtained in the first half of CBT. The first half of the CBT included conventional CBT components such as behavioural experiments on the presence or absence of safety behaviours and catastrophic self-image reconstruction, resulting from the misinterpretations of bodily sensations. These sessions are considered to sufficiently alleviate the symptoms of PD.
To date, several authors have specifically written about proposed mechanisms of change in ImRs. For example, Arntz suggested that ImRs is a psychological means to change the original memory and the content of the memory-related working selves (e.g. Arntz and Weertman, Reference Arntz and Weertman1999; Arntz, Reference Arntz2011). Others have suggested that individuals have different self-representations that are activated in response to memory recall, and whose accessibility may be modified as a result of ImRs (e.g. Brewin, Reference Brewin2006; Brewin et al., Reference Brewin, Wheatley, Patel, Fearon, Hackmann, Wells, Fisher and Myers2009; Çili et al., Reference Çili, Pettit and Stopa2017). However, based on the results of this study, it is not possible to suggest how probable mechanisms of ImRs are. Mechanisms aside, the question of the role of ImRs in the treatment of PD remains. Two studies suggest an answer to the question. Long et al. (Reference Long, Hammons, Davis, Frueh, Khan, Elhai and Teng2011b) analysed data from ImRs performed in the treatment of post-traumatic nightmares (PTNMs), suggesting that modification of post-traumatic cognitions is a mechanism of change when using a manualized PTNM ImRs intervention, and ImRs may bring about a long-term improvement in trauma-related cognitions. Veale et al. (Reference Veale, Page, Woodward and Salkovskis2015) performed a single ImRs on patients with OCD. They found that the score of the Yale-Brown Obsessive Compulsive Scale was even lower after 3 months than immediately after ImRs. These studies suggest that ImRs plays an important role in maintaining the long-term stability of a panic-free state, recovery from post-traumatic symptoms, and the prevention of recurrence. In our study, remission of PD has been maintained in 10 out of 15 patients based on follow-up data. However, as to whether ImRs contributes to maintenance of remission, evaluation (such as re-measurement of ImRs ratings) is necessary.
Limitations
The limitations of this study include the following: no control group was set, the sample size was small, there was a large sex bias among participants, and there was a lack of follow-up data on ImRs ratings. Further investigation is required for the effectiveness of ImRs for PD. It is ultimately necessary to deal with the subject of this research in a randomized controlled trial that gathers larger, more diverse samples, devises a follow-up period, and is performed at multiple institutions. Further refinement will be necessary for the cognitive model of PD, which is the basis of the effectiveness of ImRs. Furthermore, ImRs is not mandatory for all patients with PD. Even using conventional CBT without ImRs, many patients recover. Therefore, it is necessary to develop a method to predict what PD patients need ImRs.
Main points
(1) This study explored the therapeutic effects of ImRs on patients with PD to change the meaning of images and associated memories and reduce emotional distress.
(2) ImRs significantly reduced distress from images, memories and encapsulated beliefs; however, it did not change the vividness of images and memories.
(3) There was no significant correlation between the reduction in PD severity over the CBT program and the change in each rating (vividness and distress of the images and memories and conviction degree of encapsulated beliefs) in ImRs.
Acknowledgements
The authors wish to thank the anonymous reviewers for comments on an earlier version of this paper.
Conflicts of interest
Takayuki Shibuya, Yoichi Seki, Shinobu Nagata, Tomokazu Murata, Yoichi Hiramatsu, Fuminori Yamada, Mizue Yokoo, Hanae Ibuki, Noriko Minamitani, Mari Tanaka and Eiji Shimizu have no conflicts of interest with respect to this publication.
Ethical statements
The present paper followed the Ethical Principles of Psychologists and Code of Conduct as set out by the American Psychiatric Association. The Ethics Committee of the Chiba University Graduate School of Medicine approved the study protocol (reference number 1710).
Financial support
This study was supported by the Japanese Ministry of Health, Labour and Welfare under a Grant-in-Aid for Scientific Research (grant no. 22SE1P0051) (to E.S.); the Japanese Ministry of Education, Culture, Sports, Science and Technology under a part of the Special Budget for Projects (to E.S.); and Pfizer Academic Contributions (to E.S.). E.S. has received speaking honoraria at medical education events supported by Eisai, Eli Lilly, GSK, Janssen, Meiji Seika, Mochida, MSD, Otsuka, Pfizer and Yoshitomi. The funding sources had no role in the design and conduct of the study; in the collection, management, analysis and interpretation of the data; in the preparation, review or approval of the manuscript; or in the decision to submit the manuscript for publication.
Learning objectives
(1) To understand the procedure of ImRs in CBT for PD.
(2) To recognize that some patients with PD have self-negative contents not directly related to symptoms of panic attacks as common themes in the worst meaning of the image, the memory, and in the encapsulated belief.
(3) To appreciate that ImRs might be potentially effective in treating some patients with PD.
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