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A Randomized Controlled Trial on Cognitive See discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/236948493 A Randomized Controlled Trial on Cognitive Restructuring and Imagery Modification to Reduce the Feeling of Being Contaminated in Adult Survivors of Childhood Sexual Abuse Suffering... ARTICLE in PSYCHOTHERAPY AND PSYCHOSOMATICS · MAY 2013 Impact Factor: 9.2 · DOI: 10.1159/000348450 · Source: PubMed CITATIONS READS 5 233 2 AUTHORS: Kerstin Jung Regina Steil Goethe-Universität Frankfurt am Main Goethe-Universität Frankfurt am Main 4 PUBLICATIONS 28 CITATIONS 61 PUBLICATIONS 1,069 CITATIONS SEE PROFILE SEE PROFILE Available from: Kerstin Jung Retrieved on: 29 October 2015 Innovations Psychother Psychosom 2013;82:213–220 Received: August 21, 2012 DOI: 10.1159/000348450 Accepted after revision: January 13, 2013 Published online: May 22, 2013 A Randomized Controlled Trial on Cognitive Restructuring and Imagery Modification to Reduce the Feeling of Being Contaminated in Adult Survivors of Childhood Sexual Abuse Suffering from Posttraumatic Stress Disorder Kerstin Jung Regina Steil Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Goethe University Frankfurt, Frankfurt Main , Germany Key Words tion in the CRIM group than the waitlist control (WL) group. Posttraumatic stress disorder · Disgust · Childhood sexual Between-group effect sizes at follow-up were large and abuse · Cognitive therapy · Imagery · Contamination highly significant (intensity: d = 1.52, p < 0.001; vividness: d = 1.28, p < 0.001; uncontrollability: d = 1.77, p < 0.001; dis- tress: d = 1.80, p < 0.001). PTSD symptoms also yielded a Abstract greater reduction in the CRIM group than the WL group, with Background: The feeling of being contaminated (FBC) is a large between-group effect sizes (Clinician-Administered common phenomenon in survivors of childhood sexual PTSD Scale: d = 0.93, p < 0.001). Conclusions: Our findings abuse (CSA) suffering from posttraumatic stress disorder support the efficacy of the newly developed CRIM in reduc- (PTSD). Thus far, this symptom has been neglected in re- ing the FBC and PTSD symptoms in adult survivors of CSA. search and therapy. For this reason, we developed Cognitive Copyright © 2013 S. Karger AG, Basel Restructuring and Imagery Modification (CRIM), a two-ses- sion treatment (lasting 90 and 50 min) that specifically tar- gets the FBC. The present study examined the efficacy of the Empirical studies and phenomenological descriptions treatment. Methods: Thirty-four women with CSA-related [1–4] have shown that the feeling of being contaminated PTSD (mean age = 37 years) were randomized to either the (FBC) is a widespread phenomenon in survivors of sexu- CRIM group or a waitlist control group. Primary outcomes al violence. However, systematic empirical research on were intensity, vividness, and uncontrollability of the FBC, the psychopathology and interventions regarding the associated distress, and PTSD symptoms, which were as- FBC is lacking. sessed using the Clinician-Administered PTSD Scale and The FBC can be experienced in different manners. the Posttraumatic Diagnostic Scale. Outcomes were mea- Some patients describe a strong sensory component (i.e. sured pre- and posttreatment, and at the 4-week follow-up. sensing or smelling a ‘dirty film on their skin’ that cannot (M)ANOVAs were used to compare improvements across be eliminated [3] ). Other patients report distressing and conditions. Results: All FBC scores yielded a greater reduc- unrealistic convictions (i.e. that sperm or sweat particles © 2013 S. Karger AG, Basel K. Jung 0033–3190/13/0824–0213$38.00/0 Department of Clinical Psychology and Intervention E-Mail [email protected] Institute of Psychology, Goethe University Frankfurt www.karger.com/pps Postbox 11 19 32-120, DE–60054 Frankfurt Main (Germany) E-Mail k.jung @ psych.uni-frankfurt.de of the perpetrator are still on or inside their bodies [5] ; that have a less toxic meaning [8, 9] . We expected imagery that the perpetrator’s genes might have passed onto modification to be helpful because many sufferers of the them). Often, the FBC is accompanied by vivid images of FBC know rationally that they are no longer contaminat- how the remains can be seen or felt (e.g. a slimy, smelling ed but continue to believe in this contamination emotion- mass, burns, or dirty deposits). Typically, sufferers de- ally. Wells [10] introduced this distinction, postulating scribe the FBC as permanent and become more aware of that imagery is an important means of changing specifi- it when triggered by stimuli such as touching or looking cally implicit, emotionally held beliefs. at their own bodies, trauma memories [1, 5] , or interper- A first pilot study with 9 patients suffering from PTSD sonal closeness. Patients report that feeling contaminat- after childhood sexual abuse (CSA) [11] revealed strong ed means ‘being worthless’, ‘like waste’, ‘unlovable’, and pre-follow-up reductions on ratings regarding the FBC ‘contemptible’ [5] . ( d = 1.83–2.79) and PTSD symptoms (d = 0.99, p < 0.05). Behavioral consequences include engaging in safety The current study was a randomized controlled trial ex- behavior [3] (i.e. showering several times a day, using very amining the efficacy of the two-session CRIM compared hot water, vinegar, or strong cleansing materials, such as with a waitlist control (WL) in 34 female patients suffer- disinfectant and brushes, or taking care to avoid contam- ing from PTSD and the FBC following CSA. Data were ination of others when touching them or when handling collected pretreatment, posttreatment, and at the 4-week food). Many sufferers avoid looking at or touching their follow-up. We hypothesized that patients in the CRIM own bodies or avoid or leave social situations when the condition would display greater reductions in the FBC FBC is triggered or when they worry that others might feel and PTSD symptomatology than patients in the WL disgusted by them [3] . Other avoidance and escape strate- group. At an exploratory level, we tested whether chang- gies include drug abuse, or self-harming behavior. Emo- es in depressive symptoms and self-esteem would differ tional consequences of the FBC include shame, self-con- between the two groups. tempt, self-hate, guilt, and disgust toward one’s own body [3] . According to a comprehensive theoretical model by M e t h o d Jung and Steil [5] , the FBC can be developed and main- tained by dysfunctional self-appraisals following trauma- Participants Participants (n = 34) were recruited via different media or had tization. Such appraisals induce emotions such as self- been referred to specialized PTSD outpatient centers. disgust, shame, and self-contempt, which lead to and Inclusion criteria were as follows: female, 17–65 years of age, a maintain the conviction of having been contaminated. DSM-IV diagnosis of PTSD related to CSA [12] and an FBC. The The FBC may also be maintained through classical con- latter has been operationalized as ‘feeling dirty’ because of the ditioning (disgust spreads from the perpetrator to the vic- CSA, disgusted by their own bodies, or being convinced that the perpetrator´s body fluids or cells remain in or on their bodies. tim's body) and subsequent negative reinforcement of Only one of these three criteria had to be met. avoidance and escape behavior. Exclusion criteria were as follows: a lifetime diagnosis of psy- Despite patients' reports that the FBC causes immense chotic or bipolar disorder or current drug dependency according distress, until recently, there was no treatment specifically to DSM-IV criteria, body mass index lower than 16.5, mental retar- targeting the FBC. According to case reports, state-of-the- dation, and acute-severe suicidality with suicidal plans. Individuals with ongoing self-harm or high-risk behaviors were not excluded art treatments of posttraumatic stress disorder (PTSD) re- because we tried to minimize the exclusion criteria for the sake of duced classical PTSD symptoms but not the FBC [1, 6] . external validity. Participants with ongoing psychological interven- Consequently, we developed Cognitive Restructuring and tion had to interrupt this outside treatment for 5 weeks (study in- Imagery Modification (CRIM), which combines two take until follow-up assessment) while participating in our study to treatment components into a two-session intervention. prevent uncontrollable effects due to simultaneous therapy. Twenty-five of the 28 patients in the final sample ( fig. 1 ) were The first component is cognitive restructuring that aims Caucasian, and 3 were Asian. Patients were aged between 19 and to address the patients' dysfunctional appraisals relating 61 years (mean = 37.18, SD = 10.85). Eighteen were single, 7 were to the FBC. The second component is imagery modifica- married, and 3 were divorced. All but one patient had a school- tion, which has been shown to be effective at modifying leaving certificate, 3 held a university degree, and 23 had complet- implicitly stored associations, dysfunctional beliefs, and ed an apprenticeship. The period between the end of CSA and treatment intake ranged from 3 to 50 years (mean = 22.34, SD = intrusive images contributing to affective reactions in 11.67), and time suffering from the FBC ranged from 2 to 46 years emotional disorders [7] . The aim of the latter component (mean = 20.29, SD = 13.80). The mean reported age at the time of is to create effective competitor memory representations the first sexual abuse was 7.72 years (SD
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