Imagery Rescripting for Nightmares & PTSD

ABSTRACT:  The use of imagery in psychotherapy has received surprisingly little attention from researchers despite its long history in psychology and the significance of imagery in a number of psychological disorders. One procedure warranting increased attention is imagery rescripting, an imagery technique in which an image is modified in some way to decrease distress. Imagery rescripting is relatively new with a small but growing empirical base. This article briefly reviews hypothesized mechanisms for therapeutic change via imagery techniques, emphasizing imagery rescripting, and how they might be relevant in the treatment of posttraumatic stress disorder (PTSD). We review studies employing imagery rescripting as a component of treatment, followed by recommendations for future direction.

ARTICLE EXCERPTS:
"Imagery rescripting is a cognitive-behavioral technique most often used as a component of nightmare treatments, such as imagery rehearsal therapy (IRT) or, more recently, Exposure, Relaxation, and Rescripting therapy (ERRT) (Davis & Wright, 2005; Krakow, 2004; Krakow et al., 2004; Marks, 1978). IRT is currently the most commonly used technique to treat trauma-related nightmares (Davis & Wright, 2005). The effectiveness of IRT has been typically examined in a group setting over one to three sessions (Krakow, 2004). The session(s) generally include psychoeducation and cognitive skills training regarding insomnia and nightmares, an imagery rescripting component, and follow-up to discuss progress and review concerns/experiences (Krakow et al., 2000). One set of instructions for the imagery rescripting component is as follows: Choose a nightmare and modify it any way you wish; rehearse the modified nightmare for at least several minutes daily; and modify additional nightmares as necessary every 3 to 7 days, rehearsing no more than one or two new dreams per week (Krakow, Kellner, Pathak, & Lambert, 1995)."

"Some theorists indicate that imagery may be a conduit for effective therapeutic treatment of PTSD. The vivid activation of traumatic imagery in a safe setting can help survivors improve imagery control, habituate to trauma images and related physiological arousal, and identify and modify maladaptive schemas (Foa & Kozak, 1986; Lang, 1977; Laor et al., 1998; Grey, Young, & Holmes, 2002)."

It's not clear yet why imagery rescripting works.  Some believe that what helps is being exposed to the traumatic memory or nightmare until we get used to it.  But imagery rescripting worked in studies whether or not people were exposed to this painful material.  When I say "worked," I mean people slept better and felt better ("improving global sleep quality and reducing symptoms of distress.")

"Several underlying mechanisms other than exposure have been proposed to explain the
benefits of imagery rescripting, including the following:  

• The process of modifying the image results in information that is incompatible to the original experience, which further challenges and modifies maladaptive beliefs and schemas (Beck et al., 1985);
• manipulating and modifying the nightmare image results in an increase in mastery (Germain et al., 2004); 
• and it re-establishes the mind’s natural capacity to manipulate images (Krakow, 2004). 

Though these mechanisms have been proposed to explain the benefits of imagery rescripting, they have not been empirically validated, and further research in necessary."

"...studies of imagery vividness and imagery control in PTSD imply that incorporating imagery control and vivid imagery work may improve treatment outcomes (Laor et al., 1998). The results are particularly relevant to a PTSD treatment utilizing imagery rescripting because this technique specifically focuses on the client manipulating and modifying images to reduce distress. It has been suggested that the imagery rescripting component of IRT may reduce PTSD-related nightmares and sleep disturbance by re-establishing the mind’s natural capacity to manipulate images (Krakow, 2004)."

Here are some information processing theories to explain how and why using imagery works to treat PTSD:

Lang (1977) proposed a bioinformational theory for the use of imagery in treating anxiety disorders such as PTSD. This theory suggests that traumatic or fear-producing images are encoded in neural memory structures containing sensory, behavioral, physiological, and meaning elements (Lang, 1977). Eliciting these emotional images activates cognitive schemas in this fear network and can result in negative emotions, cognitions, behaviors, and physiological states. The emotional image can be used therapeutically to access the fear network, subsequent to which the information in it can be processed and the network modified. To effectively access, process, and modify this fear network, Lang stated that an individual must engage affectively and physiologically in the traumatic image through a vivid,
detailed description of the image experience (Lang, 1977; Lang & Cuthbert, 1984, 1998).

When the client gets activated by telling the story, there is an opportunity to change the associated thoughts, feelings and negative core beliefs (examples of negative core beliefs: "I should have done more," "I deserved what happened to me," "It was my fault").

Okay, this next processing theory was developed by Foa et al.:

"They extended Lang’s information-processing theory in their study of PTSD, placing more emphasis on the internal structures containing meaning of the traumatic event (Foa & Kozak, 1986). They suggest that PTSD develops in reaction to an internal neural network containing stimulus, response, and meaning representations related to the traumatic experience. This emotional processing theory suggests that to effectively emotionally process and modify the fear network and reduce fear, the network must first be activated, and then corrective, incompatible information must be integrated (Foa & Kozak, 1986). The fear network is activated through prolonged imaginal exposure during which the individual can habituate to the trauma memory and integrate corrective material about their current safety and ability to cope with the memory (Rothbaum & Mellman, 2001)."

"Finally, Chemtob, Roitblat, Hamada, Carlson, and Twentyman (1988) proposed a parallel distributed processing (PDP) model that draws from the information-processing theories of both Lang and Foa. They posit that memory structures and related emotions and actions are organized hierarchically and that information is processed in parallel distributed information processing networks. According to Chemtob et al. (1988), persons with PTSD have continued potentiation of the threat-arousal node, the highest level of the hierarchical network, and a bias to attend to threat, resulting in ongoing expectancies of threat, potentiation of the threat node, and misinterpretation of ambiguous cues. This can result in a positive feedback loop where the initial trigger activates threat-related structures and degraded stimuli triggers further activation of PTSD-related images, negative schemas, feelings, and behaviors (Chemtob et al.). Chemtob et al. argued that the hierarchical structure and its potential activation by seemingly unrelated triggers explain the intrusive symptoms of PTSD sufferers. Similar to Foa’s model, the network must first be activated, and corrective, incompatible information must be integrated through processes such as habituation (Witvliet, 1997)."


Interesting challenge or enhancement to the work of prolonged exposure:

"Prolonged imaginal exposure, largely associated with the above-mentioned cognitive theories of PTSD, is a therapeutic technique involving imagery that has been used successfully with many PTSD sufferers. Prolonged imaginal exposure has a substantial amount of empirical support regarding its effectiveness in treating PTSD resulting from a variety of traumas (Rothbaum, Meadows, Resick, & Foy, 2000). Empirical research has indicated, however, that linguistic processing of traumatic memory may not result in the physiological arousal believed to be required for habituation to occur (Cuthbert et al., 2003). Modification of traumatic images in imagery rescripting may offer an avenue for better modification of negative appraisals of the traumatic event as well as for decreasing intrusive imagery and related anxiety. Further, substituting negative imagery with positive images may result in increased ability of the PTSD sufferer to picture positive images and thoughts related to future experiences, plans, and goals (Hackmann & Holmes, 2004)."

RCTs (randomized control trials) are the gold standard for testing the effectiveness of an intervention. Here is one RCT and what they did:

"Krakow and colleagues (2000, 2001) examined the efficacy of IRT in treating chronic nightmares, reducing PTSD severity, and improving global sleep quality in women who had been sexually assaulted. Their manualized protocol consisted of three sessions in group format over a 4-week period. The first two sessions were 3 hours in length during which the following was accomplished:

• providing education about nightmares and sleep hygiene;
• challenging maladaptive beliefs related to the causes and treatment of trauma-related nightmares;
• practicing imagery with pleasant images; providing cognitive-behavioral tools that aid in managing unpleasant images;
• having participants identify one nightmare and “change it any way you wish”;
• rehearsing the modified nightmare;
• and instructing participants on how to rehearse the modified nightmares between sessions (Krakow, Hollifield, et al., 2001).

The final 1-hour session was spent examining progress in reducing sleep disturbances and discussing questions or problems. Participants in both studies reported significant decreases in nightmares and PTSD severity, as well as an improvement in sleep quality (Krakow, Hollifield, et al.; Krakow et al., 2000)."

Another RCT did something similar to the above study, but added exposure:

"Davis and Wright (2005) examined the addition of an exposure component to the IRT protocol described above. They hypothesized, based on the literature and empirical support indicating the effectiveness of exposure in reducing PTSD symptoms, that the addition of exposure would facilitate a reduction in nightmare frequency and distress symptoms. Their modified IRT protocol, ERRT, is similar to IRT except that participants spend more time exposed to the content of the original nightmare (writing and discussing it then examining trauma-related themes) and actively modifying sleep hygiene (i.e., gradual modification of negative sleep-related habits) (Davis, et al., 2003; Davis & Wright, 2005, 2006). ERRT resulted in significant decreases in reported nightmare frequency and severity, decreased symptoms of depression and PTSD, and improved sleep quality and quantity (Davis & Wright, 2007). Comparing results of the IRT and ERRT randomized controlled trials is difficult due to the differences in measures used, but ERRT appeared to result in improved sleep quality based on larger effect sizes (Davis & Wright, 2007)."

SOURCE:
Imagery Rescripting in the Treatment of Posttraumatic Stress Disorder
Mary E. Long, MS, PhD
Randal Quevillon, PhD
Journal of Cognitive Psychotherapy: An International Quarterly, Volume 23, Number 1
© 2009