The effect of imagery rescripting on low self-esteem in personality disorders.

Low self-esteem is a transdiagnostic factor in diverse psychiatric disorders,
for example anxiety (Sowislo & Orth, 2013), depression (Brown et al., 1990) and
personality disorders (Lynum et al, 2008). In a meta-analysis by Morina et al.
(2017) Imagery rescripting (IR) was found to be an effective technique in
treating diverse symptom disorders. IR as stand-alone treatment was found to be
effective for PTSD (Boterhoven de Haan et al, 2021, Raabe et al., 2015),
depression (Brewin et al., 2009, Wheatley et al. 2007), obsessive compulsive
disorder (Maloney et al., 2014) and social phobia (Frets et al. 2014, Wild et
al. 2007, 2008). In some studies (Wild et al. 2007, 2008, Frets et al. 2014)
feared negative evaluations as well as encapsulated beliefs were outcomes, but
no formal self-esteem measure was used. In social phobia there is evidence that
treatment of memories of adverse events leading to low self-esteem leads to
improvement of self-esteem and less avoidance (Frets et al. 2014).

IR as part of schematherapy was studied for personality disorders (Arntz & van
Genderen 2009, Lobbestael et al. 2010) and chronic depression (Renner et al.,
2016, 2018). Because of IR mostly being part of an extended treatment in
personality disorders, there's no research done solely into the effectivity of
IR in personality disorders, let alone into IR and self-esteem in personality
disorders. So, the exact effect or precise contribution of IR to the treatment
effect is still unknown.

Not all patients have easy access to effective treatments for low self-esteem
because of long waitinglists in specialistic mental healthcare (SGGZ) and
shortage of trained therapists, also triage is not focused on assessing low
self-esteem in specific rather than DSM-5 psychiatric disorders. IR as a short,
add-on or stand-alone module might be of value in treating self-esteem problems
as a transdiagnostic factor in diverse psychiatric disorders, amongst others in
personality disorders. But more research is needed. To my knowledge no research
has been done investigating the effect of IR on self-esteem separately, neither
in symptom disorders nor in personality disorders. This study is aimed at
investigating the effect of imagery rescripting on selfreported low self-esteem
in personality disorders and the effect on diverse complaints (anxiety,
depression), wellbeing and core cognitions. This might be a step into composing
an effective, confined self-esteem treatment module for personality disorders.

This study is aimed at investigating the effect of imagery rescripting on
selfreported low self-esteem in personality disorders and the effect on diverse
complaints (anxiety, depression), wellbeing and core cognitions. This might be
a step into composing an effective, confined self-esteem treatment module for
personality disorders.

Based on the examples mentioned below the design of the current study has been
developed, using a single case experimental design (SCED) to answer following
research questions:




Research questions

1. What is the effect of imagery rescripting on low self-esteem and core
cognitions in personality disorders (primary outcome)?

2. What is the effect of imagery rescripting on symptoms of depression, anxiety
and wellbeing (secondary outcomes)?

3. Is imagery rescripting (B) more effective than imagining a positive memory
(C)?

4.Is the effect of imagery rescripting mediated through reduction of symptoms,
change of core cognitions or reduction of vividness of adverse memories?



Hypotheses
1. Imagery rescripting (versus passive and active control conditions) leads to
increased self-esteem as seen in improving scores on a self-esteem selfrapport
questionnaire and a rise in credibility of positive core cognitions

2. Imagery rescripting (versus passive and active control conditions) leads to
a decrease in symptoms of anxiety, depression, and increased wellbeing.

3. The *rescripting* element is crucial, i.e., Imagery rescripting has a
stronger effect on improving self-esteem and decreasing symptoms than
activating a positive memory

4. A reduction of credibility of core cognitions precedes the reduction of
symptoms

Studies showing promising results for IR reached significance even with small
sample sizes. For example, the study of Brewin et al 2009, with N=10 depressed
patients and on average 8 sessions after three weeks of baseline control, in
which hierarchical linear modelling demonstrated large treatment effects. Arntz
et al (2013) accomplished a concurrent (to control for historical effects)
multiple base line case series study in which refugees (N=6) were randomly
assigned to a baseline length of 6 to 10 weeks (to control for time effects),
followed by a 5 weeks exploration phase (to control for attention effects) and
10 weekly treatmentsessions (IR), that showed a large improvement on PTSD
symptom severity (with 9 out of 10 patients remitting from PTSD) as well as
depression rates. The study of Frets et al. (2014) with N=6 patients with
social phobia, with an A-B design with three weeks baseline control, showed
improvement on interaction- and performance anxiety and avoidance after 5-17
weekly sessions (average 11.2). Evidence for the use of IR in treatment of
obsessive-compulsive disorder (OCD) is found by Maloney et al. (2019). In an
A-B-C-D single case experimental design with follow-up, with thirteen
participants and - after assessment (A) - and a randomized baseline (B), the
treatment phase (C) consisting of 1-6 weekly sessions of IR was needed for
twelve out of thirteen patients to achieve a 35% improvement on the Y-BOCS.
Based on these examples the design of the current study has been developed,
using a single case experimental design (SCED) to answer the above mentioned
research questions:

Study design:

Design: Single case series design with variable randomize baseline, consisting
of a treatment condition and a passive and active control condition: ABACA,
AABACA, AAABACA, ACABA, AACABA, AAACABA

A= 2 weeks, AA= 4 weeks, AAA= 6 weeks randomized baseline waitinglist
condition, no intervention

B= imagery rescripting: activation and rescripting of an emotional memory (2
sessions)

C= imagining a positive memory (2 sessions)

Randomization will be executed by an independent person by drawing *straws* out
of 12 options (2 per design) for each included participant (like Arntz et al.,
2013)

Treatment protocol: IR protocol based on Arntz & Weertman (1999), Schmucker et
al. (1995), Wild et al. (2007, 2008), Wheatley et al. (2007).

There is no risk to subjects.There is a mild cognitive and emotional load due
to the intervention which is alongside the treatmet as usual. Because the
in-patiënts are already on the location there's no extra burden due to
traveltime. Questionnaires can be filled out at home digitally.
There is also a slight burden due to filling out the questionnaires for this
study (maximum 40-50 minutes per week).

Since this research is subject to the WMO, an exemption has been requested for
a trialsubject Insurance.