Single-Session Imagery Rescripting for Social Anxiety Disorder

140 Pages·2014·1.55 MB·English

Single-Session Imagery Rescripting for Social Anxiety Disorder:
Efficacy and Mechanisms.
by
Susanna Gehring Reimer

A thesis
presented to the University of Waterloo
in fulfilment of the
thesis requirement for the degree of
Doctor of Philosophy
in
Psychology

Waterloo, Ontario, Canada, 2014

© Susanna Gehring Reimer 2014
Author’s Declaration

I hereby declare that I am the sole author of this thesis.
This is a true copy of the thesis, including any required final revisions,
as accepted by my examiners.
I understand that my thesis may be made electronically available to the public.

ii
Abstract

Cognitive theories of social anxiety propose that negative mental imagery plays a central role in the
maintenance of the disorder. Research has indicated that the content of such mental imagery represents
negative core beliefs and derives from specific formative, negative autobiographical events.
This dissertation examines the efficacy and mechanisms of imagery rescripting (IR), a novel
intervention for social anxiety that works with the content of the negative autobiographical event to
transform embedded meaning and corresponding affect. A total of 27 participants with a clinical
diagnosis of SAD completed diagnostic assessment and a semi-structured interview designed to identify
recurrent images, corresponding autobiographical memories, and the personal meaning these represent
to the individual. Then, participants were randomly assigned either to waitlist or a single session of IR.
Results from between- and within-group analyses indicated superiority of IR to waitlist as evidenced by
significant changes in conjunction with IR from pre- to post-intervention in symptoms of emotional
distress and core negative cognitions as well as other hypothesized outcome variables. These gains were
generally maintained at 1-week and 1-month follow-up, with substantial effect sizes. Results indicated,
in particular, that IR leads to robust changes in self-related cognitions, which, in turn, lead to decreases
in SAD symptoms. Implications and future directions are discussed.
iii
Acknowledgements
First and foremost, I must acknowledge the tremendous contributions of my supervisor, Dr.
David Moscovitch, to this dissertation and to my education in clinical psychology. Throughout my
graduate training, David has consistently held my development as the guiding principle in his
supervision, prioritizing growth at every opportunity and offering his considerable wisdom with great
flexibility. He has alternately challenged, coached, and supported me in my work, helping cultivate my
strengths and fearlessly addressing my weaknesses. His zeal for research has been contagious, and our
work together has been a true pleasure. I am profoundly grateful for his mentorship.
I am thankful to the members of my committee: Jonathan Oakman, for his keen and critical eye,
statistical prowess, and engagement; and Christine Purdon, for her careful reading and enthusiastic
support of this project and my development as a clinician. I am grateful to Rita Cherkewski, Maureen
Stafford, and Bill Eickmeier, for administrative and technical support; and to Rachel Neal and Klint
Fung for their assistance with data entry and programming.
While this dissertation was happening, so was life. I owe a huge debt of gratitude to my mother,
Arlene, for the boundless generosity of her parenting and grandparenting throughout this project. Also to
my dad, Bo, for his unflagging enthusiasm; to Marg, for her kind patience; and to Jim for his love. Katie,
Christina, Peter G., Peter S., Schmidt, Micah, Erin, David, and Carol: for their continued interest in my
work and cherished grounding in reality. And to my dear friends and community, for being there
throughout this process. I am grateful to S & J who have been the light in every day.
Finally, Thomas: I would not and could not have completed this dissertation without him. His
love, intellect, and partnership – full-on, non-stop – have made this all make sense.
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Dedication

To my family.
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Table of Contents

Abstract iii
Acknowledgments iv
Dedication v
Table of Contents vi
List of Figures ix
List of Tables x
1.0 Introduction 1
1.1 Images in Social Anxiety 1
1.2 Overview of the Present Study 10
1.3 Primary Questions and Hypotheses: Efficacy of Imagery Rescripting 13
1.3.1 Symptom reduction 13
1.3.2 Changes in negative core beliefs about self, others, and the world 15
1.3.3 Changes in memory and imagery characteristics 16
1.4 Secondary Questions and Hypotheses: Specific Therapeutic Processes 16
1.4.1 Differentiation of prior self and current self 16
1.4.2 Perceived shift in empowerment 17
1.4.3 Changes in compassion, forgiveness and acceptance 17
1.4.4 Gaining objective distance (or defusion) from beliefs 18
1.5 What Explains Symptom Change? 19
2.0 Methods and Materials 21
2.1 Participants 21
2.2 Procedure 22
2.3 Materials 23
2.3.1 Clinician-Researcher Administered Interviews 23
2.3.1.1 Mini-International Neuropsychiatric Interview 23
2.3.1.2 Waterloo Images and Memories Interview 23
2.3.1.3 Associated Cognitions Supplement 24
2.3.2 Self-Report Measures 25
2.3.2.1 Social Phobia Inventory 25
vi
2.3.2.2 Liebowitz Social Anxiety Scale 25
2.3.2.3 Depression Anxiety Stress Scales 26
2.3.3 Subjective ratings 27
2.3.3.1 Image items 27
2.3.3.2 Memory items 28
2.3.3.3 Associated cognitions items 29
2.3.3.4 Drexel Defusion Scale 30
2.4 Experimental Procedures 31
2.4.1 Overview 31
2.4.2 Imagery rescripting intervention 31
3.0 Results 34
3.1 Preliminary Analyses 34
3.1.1 Descriptive statistics 34
3.1.2 Change prior to IR 34
3.2 Efficacy of IR 35
3.2.1 Changes in SA symptoms 35
3.2.2 Changes in depression symptoms 37
3.3 Change processes during IR 36
3.3.1 Changes in core beliefs 37
3.3.2 Changes in empowerment of self 39
3.3.4 Changes in differentiation of self 40
3.3.5 Changes in compassion, forgiveness, and acceptance 41
3.3.6 Changes in defusion 42
3.3.7 Changes in imagery qualities 45
3.3.8 Changes in memory qualities 46
3.4 Mechanisms of Treatment Efficacy 48
4.0 Discussion 50
4.1 Efficacy of Imagery Rescripting: Symptom Reduction 50
4.2 Effects of Imagery Rescripting on Specific Therapeutic Factors 51
4.2.1 Changes in negative core beliefs 51
4.2.2 Differentiation of current and prior self 52
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4.2.3 Compassion, forgiveness, and acceptance towards self and others 54
4.2.4 Cognitive defusion 55
4.2.5 Imagery and memory qualities 56
4.3 Mechanisms of Treatment Efficacy 56
4.4 Theoretical and Practical Implications 57
4.4.1 Centrality of the self in cognitive models of social anxiety 57
4.4.2 Spontaneous vs. planned challenging of underlying cognitions 58
4.4.3 Imagery Rescripting: Is it CBT? 60
4.5 Limitations 61
4.6 Future Directions 63
Footnotes 67
References 72
Table of Appendices 103

viii
List of Figures

1 Present-focused cognitive model of social anxiety 82
2 Transdiagnostic cognitive model of anxiety 83
3 Social anxiety ratings on the SPIN in the Treatment group over time 84
4 Social anxiety ratings on the SPIN in the WL group over time 84
5 Social anxiety ratings on the SPIN in both groups at matched time points 85
6 Strength of original and updated core beliefs over time 85

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List of Tables

1 Sample characteristics 86

2 Means and standard deviations for control and treatment groups on 87
symptom measures across time points

88
3 Table of associated cognitions

4a Summary of Repeated Measures ANOVAs of change in compassion, 99

forgiveness, and acceptance towards self and others

4b Between-groups comparisons of compassion, forgiveness, and acceptance 100
towards self and others at matched time points, post-IR and WL

5 Correlations of change in process variables and in SPIN scores 101

x