A Randomized Controlled Trial on Cognitive

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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

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Kerstin Jung Regina Steil Goethe-Universität Frankfurt am Main Goethe-Universität Frankfurt am Main

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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; distress: 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-session treatment (lasting 90 and 50 min) that specifically targets 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 maintained 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 = 4.29), and the abuse

214 Psychother Psychosom 2013;82:213–220 Jung/Steil DOI: 10.1159/000348450 Interested in the CRIM treatment (n = 79)

Excluded after telephone screening (n = 31) Meeting at least 1 exclusion criterion (n = 10) Not meeting all inclusion criteria (n = 21)

Appearing for clinical assessment (n = 34) Not appearing for clinical assessment (n = 14)

Allocation (n = 34)

Allocated to treatment group (n = 17) Allocated to waitlist group (n = 17)

Nonstarters (n = 2) Nonstarters (n = 2) Received allocated intervention (starters) (n = 15) Received allocated intervention (starters) (n = 15) Excluded from study (n = 1) Excluded from study (n = 1) Completers (t2) (n = 14) Assessed at t2 (n = 14)

Analysis Analysis

Included in analysis (n = 14) Included in analysis (n = 14) Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Fig. 1. Patient flow through enrollment, allocation, and analysis. t2 = Follow-up.

lasted 6.84 years (SD = 5.21) on average. Most participants report- T r e a t m e n t ed that the abuse had been severe, included penetration (71.4%), The study was conducted at three specialized PTSD outpa- and was inflicted by a relative (71.4%). Patients had an average of tient centers, one at Frankfurt University and the other two at 3.36 DSM-IV Axis-I or Axis-II diagnoses (SD = 1.06). The most large psychiatric hospitals in Bonn and Cologne, between June frequent comorbid diagnoses were major depressive disorder 2010 and October 2011. For participants assigned to the treat- (57.1%), eating disorders (32.1%), borderline personality disorder ment condition, CRIM started 1 week after pretreatment assess- (32.1%), and social anxiety disorder (25.0%). Upon study intake, ment, whereas for participants assigned to WL, treatment with all participants had previously received psychological treatment. CRIM started 5 weeks after pretreatment assessment. CRIM (for Twenty-three (82.1%) participants had received trauma-focused a more detailed description, see [5] ) comprises one treatment psychological treatment. session (approximately 90 min) and one booster session (ap- After the intake assessment, written informed consent was ob- proximately 50 min). The therapist (the first author) treated 9 tained. Subsequently, eligible participants were randomly assigned pilot cases [11] before the reported randomized control trial in a 1: 1 ratio to either the CRIM or WL group. The study was ap- started. She was supervised by the second author on a weekly proved by the Medical Ethical Board of Frankfurt University. basis. Treatment Session. Initially, the therapist and patient examine Assessment of Diagnoses the characteristics of the FBC (e.g. What does this feel like? Does The Structured Clinical Interview for DSM-IV Axis-I Disor- it have a sensory component or is it a form of consciousness? ders (SCID-I) [13] , the Borderline Section of the International Per- What does it mean?). Subsequently, the therapist instructs the pa- sonality Disorder Examination (IPDE) [14], and the Clinician- tient to gather information via the internet (an internet-connect- Administered PTSD Scale (CAPS) [15] were administered by a ed laptop and calculator are provided in the treatment room) on trained clinician rater before randomization. A CAPS follow-up how frequently the patient’s dermal cells in trauma-related body assessment was conducted by one of two other trained clinicians, regions have literally been rebuilt completely since her last contact who were blind to the condition assignment. To assess interrater with the perpetrator. Skin cells rebuild every 4–6 weeks; mucous reliability, we used a joint interview method [16]. Interrater reli- membranes rebuild even more frequently. For example, if the last ability of the total CAPS score was good (r = 0.97). contact with the perpetrator occurred ten years ago, the patient

Treatment for the Feeling of Being Psychother Psychosom 2013;82:213–220 215 Contaminated DOI: 10.1159/000348450 will calculate that dermal cells of her hands or thighs have been Data on the different self-report measures were collected completely rebuilt at least approximately 120 times since then. If 1 week after study intake (t0), 2 weeks after study intake (t1), and the FBC relates to other body cells as well, the internet research is 5 weeks after study intake (t2) in both study arms. The CAPS was extended to renewal of blood and other body cells. It appeared to administered at t0 and t2. be necessary to refer to the unique convictions of the patient to induce a meaningful change. Statistical Analysis The research is completely patient-led, although the patient can We conducted repeated measures multivariate analyses of vari- ask the therapist for assistance. Next, therapist and patient discuss ance (MANOVAs) with treatment (CRIM vs. WL) as a between- what this new information means to the patient (i.e. ‘Not one of subjects factor, time as a within-subjects factor (t0, t1, t2), and the dermal cells which cover my body and my body orifices now scores on the intensity, vividness, and uncontrollability of the FBC has been in contact with the perpetrator or his body fluids...’). The and the associated distress (1st MANOVA) as well as scores on the therapist confronts the patient with her own ideas on contamina- depression and self-esteem measures (2nd MANOVA) as depen- tion examined at the beginning of the session (e.g. perpetrator’s dent variables. Given that CAPS ratings were only conducted sperm has sedimented in a cavity of the body). Typically, the inter- twice, whereas PDS ratings were conducted three times, we calcu- net research and following discussion help the patients to realize lated two separate repeated-measures univariate analyses of vari- rationally that they cannot still be contaminated. The therapist ance (ANOVAs) with treatment (CRIM vs. WL) as a between- then instructs the patient to develop an idiosyncratic imagery rep- subjects factor, time as a within-subjects factor (t0, t2, respectively, resenting the process of skin or cell renewal. This imagery is en- and t0, t1, t2), and scores on the CAPS and scores on the PDS as riched with details on the different sensory modalities. The thera- dependent variables. In cases in which the criterion of sphericity pist emphasizes that the patient can use any imagery she wants and was not fulfilled, we used Greenhouse-Geisser corrections. that it does not need to be realistic because the image is only a type To account for potentially confounding effects, we conducted of vehicle for transporting the realistic information ‘from the head additional analyses that incorporated information regarding to the heart’. Next, the therapist instructs the patient to activate the whether patients had received other psychological treatments FBC, and associated distressing images, by imaging a daily life sit- before or after study participation as covariates. The center where uation in the last week during which the feeling was present, until the study treatment was conducted (i.e. Frankfurt vs. Bonn vs. the FBC reaches a moderate intensity. After that, the patient is Cologne) and eating disorder status (a current diagnosis of an eat- guided to use her new idiosyncratic imagery of skin renewal. The ing disorder vs. no current diagnosis of an eating disorder) were therapist attempts to encourage the patients to adopt a first-person also controlled for. field perspective, seeing images through their own eyes. For home- Effect sizes for pre-post comparisons of continuous data (gain work, patients are asked to listen to a tape of the guided imagery scores) were calculated as: modification at least once a day over a period of 7 days and com- plete homework protocols. The booster session is administered 1 week after the treatment session. Effects of the treatment on the patient, questions related to the intervention, problems in using the method and its imple- For quantification of between-group differences in improvements mentation in everyday life are discussed. over time, Cohen’s d based on pooled standard deviations was ap- plied to the post-scores and follow-up scores. We constructed the Study Endpoints and Trial Design 95% CIs around the effect sizes. Primary outcome measures: the FBC was assessed during the We had no data loss for the patients who attended the treat- week between treatment sessions by four daily ratings regarding ment sessions. Given that patients filled in the self-report ques- intensity, vividness, and uncontrollability of the FBC and the re- tionnaires in the week after study intake, we only had pretreatment sulting distress, similar to those used by Hackmann et al. [17] on CAPS ratings but no pretreatment self-report data for the patients intrusive memories. Patients were asked to rate the four parame- not attending the treatment sessions. This allowed us to calculate ters on visual analogue scales ranging from 0 = ‘not at all’ to 100 = intent-to-treat (ITT) analyses for the CAPS but not for the other ‘extremely’. Of the seven daily ratings, the mean values per week outcome measures. We also calculated ITT analyses for all out- were calculated. The internal consistency of the scales was α = come measures, including the patients we had to exclude due to 0.91. PTSD symptomatology was assessed using the German ver- protocol violations. In general, we report completers’ analyses. The sion of the well-validated Clinician-Administered PTSD Scale results based on ITT analyses are specifically labeled as such. (CAPS) [15] , a structured clinical interview measuring the fre- We used a significance level of p < 0.05 (two-tailed) for all anal- quency and severity of each of the 17 symptoms listed in the DSM- yses. In accordance with Shaffer [21] , we used a Bonferroni adjust- IV diagnosis of PTSD (range 0–136; Cronbach’s α = 0.92). Fur- ment, considering the number of tests, to avoid an accumulation thermore, the frequency of the DSM-IV criteria was established of type I errors. using the German version of the Posttraumatic Diagnostic Scale To ensure that change in the CAPS was outside the range that (PDS) [18] , a self-report questionnaire (range 0–51; Cronbach’s is easily explained by measurement unreliability, reliable change α = 0.94). was calculated, as outlined by Jacobson and Truax [22]. The reli- Secondary outcome measures were the Beck Depression Inven- able change index was 19.62, based on data according to Schnyder tory (BDI-II) [19] , one of the most widely used self-report instru- and Moergeli [15] . Remission was defined as not meeting DSM-IV ments for measuring the severity of depressive symptomatology, PTSD criteria in the CAPS. Initially, t tests and χ 2 tests compared and the Rosenberg Self-esteem Scale (RSES) [20], which is the most baseline characteristics between treatment conditions. Statistics widely used self-esteem measure internationally. were calculated with SPSS® Version 19.0.

216 Psychother Psychosom 2013;82:213–220 Jung/Steil DOI: 10.1159/000348450 An a priori power analysis was conducted, with an expected (F (1.63, 42.26) = 17.97, p < 0.001, t1: d = 0.75, 95% CI between-group effect size of 1.0 for the PTSD scores because the [–0.02, 1.52]; t2: d = 1.52, 95% CI [0.68, 2.36]), its vividness t0–t2 effect size in the pilot sample was nearly 1.0. We expected a comparable between-group effect size based on the assumption (F (2, 52) = 19.75, p < 0.001, t1: d = 0.47, 95% CI [–0.28, that there would not be major effects in the WL group because 1.22]; t2: d = 1.28, 95% CI [0.47, 2.09]) and uncontrollabil- 5 weeks is a short period. The power analysis resulted in a sample ity (F (2, 52) = 21.39, p < 0.001, t1: d = 1.03, 95% CI [0.24, size of 28 participants. 1.82]; t2: d = 1.77, 95% CI [0.90, 2.64]), as well as the associated distress (F (1.44, 37.50) = 27.58, p < 0.001, t1: d = 1.27, 95% CI [0.46, 2.08]; t2: d = 1.80, 95% CI [0.92, 2.68]), R e s u l t s were significantly larger for the CRIM group than the WL group, with very large t2 between-group effect sizes Patient Flow of ≥ 1.28. The ITT analyses that included the patients ex- As shown in figure 1 , of the 79 patients who were included from study participation showed comparable re- terested in participating, 48 were eligible. Of these, 14 sults, with t2 between-group effect sizes of d ≥ 1.29. Table 1 women decided not to participate after telephone screen- shows the mean values, standard deviations, and the t0 ver- ing. 34 participants were randomly assigned to either the sus t1 and t0 versus t2 effect sizes for the different outcome CRIM group (n = 17) or WL group (n = 17). Two patients measures. in each condition decided against treatment after ran- In a repeated measures ANOVA, a significant condi- domization and were defined as nonstarters. Further, 2 tion x time interaction for the CAPS was obtained, indi- patients (1 in each condition) were excluded from the cating a significantly larger reduction in the blinded clini- study due to protocol violations, specifically, because they cians ratings of PTSD severity from pretreatment to fol- had received further psychological treatment while par- low-up in the CRIM group compared with the WL group, ticipating in the study. No patient dropped out of treat- with a large t2 between-group effect size (F (1, 26) = 16.01, ment. p < 0.001, d = 0.93, 95% CI [0.15, 1.72]). The ITT analysis On average, the treatment sessions lasted 95.57 min for the CAPS including the nonstarters and excluded pa- (SD = 8.39) for the first session and 69.64 min (SD = tients showed a comparable result, with a t2 between- 9.86) for the booster session. After discharge (after the group effect size of d = 1.01. At t2, 7 patients (50.0%) follow-up assessment), 8 patients (57.1%) in the CRIM displayed reliable change in the CAPS, and 5 patients group and 7 patients (50.0%) in the WL group returned (35.7%) showed remission, compared with 1 (7.1%) reli- to their previous outpatient psychological treatments. able change and 1 (7.1%) remission in the WL. No patient Furthermore, 1 patient (7.1%) in the WL group started displayed deterioration in the CAPS. new outpatient psychological treatment, and 6 patients An ANOVA analyzing the PDS ratings revealed a sig- (42.9%) in each condition received no further treat- nificant condition x time interaction, with a large t2 be- ment. tween-group effect size ( F (2, 25) = 3.45, p = 0.047; t1: d = 0.84, 95% CI [0.07, 1.61]; t2: d = 0.91, 95% CI [0.13, 1.69]). Comparability of Patients in both Conditions The ITT analysis showed a trend towards significance Independent sample t tests and χ2 tests on baseline (p = 0.05; t2 between-group effect size d = 0.95). scores revealed no significant differences between the Secondary Outcome Measures. A MANOVA analyz- CRIM and WL groups on any measures (age, time elapsed ing the BDI-II and RSES ratings revealed a significant since the last CSA, age at first sexual abuse, duration and condition × time interaction (F (4, 22) = 4.00, p = 0.014), severity of the CSA, type of abuse and perpetrator, dura- with a larger increase in the RSES score in the CRIM tion of the FBC, number of BPD criteria, former in- and group compared with the WL group ( F(1.60, 40.06) = outpatient treatment experiences, CAPS, PDS, BDI-II, 5.19, p = 0.009, t1: d = 0.76, 95% CI [–0.01, 1.53]; t2: d = RSES, and FBC scores). 0.72, 95% CI [–0.04, 1.48]). The t2 between-group effect size was medium. The condition x time interaction of the Treatment Effects BDI-II clearly did not attain statistical significance Primary Outcome Measures. In the MANOVA, which ( F(1.63, 40.79) = 2.09, p = 0.144; t1: d = 0.49, 95% CI analyzed different components of the FBC, an interaction [–0.26, 1.24]; t2: d = 0.64, 95% CI [–0.13, 1.41]). The ITT between condition and time was strong and highly signifi- analysis showed comparable results, with a t2 between- cant, with changes in the expected direction (F (8, 19) = group effect size of d = 0.69 for the RSES and a non-sig- 4.16, p = 0.005). Improvements in the intensity of the FBC nificant effect size of d = 0.64 for the BDI-II.

Treatment for the Feeling of Being Psychother Psychosom 2013;82:213–220 217 Contaminated DOI: 10.1159/000348450 Additional analyses that included whether patients had received psychological treatment before or after study participation, the different study centers (i.e. Frank- (95% CI) furt vs. Bonn vs. Cologne), and eating disorder status t0t2 –0.26 n.s. (–1.00, 0.48) –0.25 n.s. (–0.94, 0.54) –0.20 n.s. (–0.94, 0.54) –0.29 n.s. (–1.03, 0.46) (–0.62, 0.86) 0.0 n.s. (–0.76, 0.72) –0.21 n.s. (–0.95, 0.53) –0.08 n.s. (–0.82, 0.66) d showed that these covariates were not related to the level or course of all endpoints.

* (95% CI)

t0t1 D i s c u s s i o n d (–0.90, 0.58) (–0.94, 0.54) (–0.85, 0.63) (–1.04, 0.44) (–0.61, 0.87) (–0.84, 0.64) –0.26 (–1.00, 0.48)

The current study investigated the efficacy of CRIM, a cognitive-behavioral two-session treatment program, which targets the FBC in women with CSA-related PTSD. Significantly larger improvements were found regarding the intensity, vividness, and uncontrollability of the FBC and the associated distress in CRIM compared with the WL condition. Between-group effect sizes at the 4-week follow-up were large (d = 1.28–1.80). Furthermore, the brief treatment significantly reduced PTSD symptomatology in a severely affected patient group. A meta-analysis and review of psychological treatments for 58.1±13.951.6±21.4 60.8±18.756.9±19.6 56.1±23.1 63.0±22.855.9±19.0 59.3±24.8 57.7±26.8 –0.16 n.s. 82.6±16.6 61.9±21.3 61.5±25.3 –0.20 n.s. 33.6±9.7 61.9±22.9 –0.11 n.s. 29.4±14.0 –0.30 n.s. 32.5±8.320.6±5.7 30.9±15.8 33.8±9.9 80.4±18.3 32.5±15.8 19.2±5.4 0.13 n.s. –0.10 n.s. 20.2±5.3 PTSD after 0.12 n.s. CSA in adults showed medium effect sizes, with Hedges g = 0.77 [23] and d = 0.44 [24] , compared with control conditions. Most of these interventions lasted between 10–20 sessions of 60–90 min each. In the current study, the *** *** *** *** *** * * (95% CI) mean ± SD mean ± SD mean ± SD between-group effect sizes at follow-up were large for t0t2 d 1.93 (1.03, 2.83) 1.73 (0.86, 2.60) 2.04 (1.13, 2.95) 1.99 (1.08, 2.90) 0.90 (0.12, 1.68) 0.56 (–0.20, 1.32) 0.23 n.s. (–0.51, 0.97) 0.35 (–0.40, 1.10) CAPS and PDS (d = 0.93 and d = 0.91, respectively). This effect is remarkable because we reduced the exclusion criteria to a minimum, resulting in a population with high levels of comorbid symptomatolgy and symptom severity, *** *** *** ** * (95% CI) ** with a mean CAPS score of 80.6 at t0. t0t1 d 1.05 (0.26, 1.84) 076 (0.01, –1.53) 1.26 (0.45, 2.07) 1.33 (0.51, 2.15) 0.56 (–0.20, 1.32) (–0.53, 0.95) 0.28 (–0.46, 1.02) What might explain the large effects on the FBC?

. Cognitive factors might include a modification of the rationally held belief as a result of the internet research and subsequent disputation. Shame might have been reduced with the patient learning that she is not the only one to suffer from such symptoms. Behavioral factors might include habituation through speaking in detail about the FBC, thus activating and confronting associated feelings. What might be the specific mechanisms of change of p ≤ 0.001. n.s. = Not significant the imagery modification part of the treatment? Accord- *** ing to Brewin’s revised dual representation theory [8] , CRIMPre-mean ± SD mean ± SD Post- mean ± SD Follow-up ES t0-t1 ES t0-t2re- P Post-imagery Follow-up WL ES t0-t1 modification ES t0-t2 combines retrieving abstract, flex- ible, contextualized representations and reporting on the p ≤ 0.01.

** content of inflexible, sensory-bound representations at the same time. This ensures that all relevant sensory- Clinical variables in the CRIM and WL groups at pretreatment (t0), posttreatment (t1), follow-up (t2) bound material can be associated with newly elaborated p ≤ 0.05.

* representations. A repetition of this new link results in FBC intensityFBC vividness 65.0±16.8FBC uncontrolability 60.7±20.0 48.0±15.6 62.0±20.9FBC distress 37.3±17.5 45.3±23.3 32.7±16.7 CAPS 23.0±17.4 29.0±17.1 PDS 60.8±18.1 38.1±15.9BDI-IIRSES 25.4±17.4 80.6±20.2 30.2±10.0 26.6±14.0 24.4±11.0 23.9±12.4 22.1±7.8 24.4±10.8 60.9±23.3 23.6±11.9 24.4±8.0 0.21 n.s. 24.8±7.4 Table 1. more accessible and more positive representations that

218 Psychother Psychosom 2013;82:213–220 Jung/Steil DOI: 10.1159/000348450 can compete effectively with previously dominant nega- research, although an internal consistency of α = 0.91 tive ones. The high speed of experienced change can be seems promising. explained by the hypothesis that working with powerful More than half of the patients in our sample were re- imagery is similar to having an actual experience [7] . ceiving other psychological treatment. By requiring inter- There are various possible explanations of the large ruption of other treatments while participating in our effect of CRIM on PTSD symptoms. Firstly, when the study, we attempted to prevent uncontrollable effects patients realized that they were able to quickly reduce caused by simultaneous therapy. However, delayed ef- the FBC, some were encouraged to reduce their avoid- fects of previous therapeutic interventions might also ac- ance behavior, which might previously have prevent- count for treatment success. Covariate analyses revealed ed changes in negative trauma-related appraisals. For that previous interventions were unrelated to the level or example, one patient took a bath for the first time in course of the different outcome measures. 30 years. Secondly, the FBC may be a central component Furthermore, the booster session was originally con- of the patients’ self-image. Exploring the characteristics ceptualized to last 50 min. However, it lasted 69.64 min and meanings of the FBC may help to detect, and change (SD = 9.86) because we used the booster session to answer the most toxic self-referred cognitions, given that im- patients’ general questions on PTSD and trauma-focused ages appear to reflect a wider range of idiosyncratic en- therapy. capsulated meanings than thoughts alone [7] . Thinking CRIM was administered by one therapist and super- more positively about themselves and experiencing vised by one senior therapist. Therefore, it remains un- mastery over distressing emotions may reduce patients’ clear whether parts of the treatment effects should be at- perceived worthlessness and helplessness [25]. This cor- tributed to their individual traits and expertise with the responds with the significant increase in self-esteem FBC. Furthermore, treatment fidelity was ensured by found in our study. Thirdly, patients may successfully video-based supervision, but we did not systematically apply the CRIM approach to other central cognitions. collect any data on treatment fidelity, such as video-based For instance, one patient reported that she developed independent ratings of manual adherence. further imageries of strength and success after the treat- In addition, participants were recruited through spe- ment session. cifically identifying the FBC as a problem for which they No patient dropped out of CRIM. One reason for this wanted help, which may have increased effect sizes. Four low dropout rate may be that the intervention is short, women decided against treatment after the pretreatment leaving little room for dropping out. However, the in- assessment session. Statistical analyses revealed that these tended mastery experience, lack of formal exposure to patients did not differ from the 28 women included in our trauma-related memories [26], and the fact that the im- study sample. Thus, not all eligible patients will agree to agery was individually developed by the patients might the treatment. However, the 12% rate of nonstarters does have contributed to the high compliance. Furthermore, not seem high compared with other intervention studies because the treatment did not cause any form of crisis [27–29] . or deterioration of psychopathology, it appears to be Considering these limitations, the results of the pres- safe. ent study suggest that CRIM is the first effective and safe In the present study, we used CRIM as a short-term treatment for the FBC in adult patients suffering from stand-alone treatment. However, our clinical experience PTSD after CSA. Furthermore, this treatment seems to shows that CRIM can also easily be embedded in a more have strong effects on PTSD symptomatology. Future comprehensive cognitive behavioral treatment program studies should assess whether CRIM can also be used to of PTSD [4] . Initial treatment success with CRIM might modify other dysfunctional cognitions related to PTSD even motivate patients to attend a previously avoided after different types of trauma. state-of-the-art trauma-focused treatment.

L i m i t a t i o n s Acknowledgements The limitations of the present study are primarily the small sample size, the short follow-up, the absence of an We are grateful to Volkmar Höfling for his collaboration on statistical analyses. active control group and a lack of clinician ratings for the FBC. Moreover, the validity and reliability of the visual analogue scales on the FBC must be verified by further

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