1 引言

心理表象(mental imagery)與現(xiàn)實知覺不同,是個體在沒有并行感覺輸入時的知覺經(jīng)驗(Kosslyn,Thompson,&Ganis,2006),以及對知覺經(jīng)驗的模擬或再創(chuàng)造(Kosslyn,Ganis,&Thompson,2001;Pearson,2007)。心理表象的信息來源與現(xiàn)實知覺不同,前者主要來自記憶或想象,后者則來自直接的感覺登記(We?lau&Steil,2014)。心理表象的類型與不同感覺通道的知覺相對應(Moulton&Kosslyn,2009),比如視覺表象、聽覺表象等,并且心理表象的感覺屬性與純粹的言語或抽象特征不同(Hackmann,1998)。認知神經(jīng)科學的研究發(fā)現(xiàn),心理表象與現(xiàn)實知覺具有相似的神經(jīng)機制(Herholz,Halpern,&Zatorre,2012;Kosslyn et al.,2001,2006;Schacter,Addis,&Buckner,2007;Schacter et al.,2012),心理表象因此被認為具有現(xiàn)實仿真功能(Moulton&Kosslyn,2009;Schacter et al.,2007)。另外,心理表象加工能力還存在個體差異(Burnett Heyes,Lau,&Holmes,2013;Pearson et al.,2013),主要體現(xiàn)在4種心理表象的子加工(sub-process)：(1)表象生成,或是在一個與感覺輸入共用的“描述緩沖區(qū)”(depictive buffer)中形成表象;(2)表象檢查,即將注意力轉(zhuǎn)移到表象的某一特定方面;(3)表象保持,或保留某個表象用以檢查;(4)表象轉(zhuǎn)化/操縱,如表象旋轉(zhuǎn)、縮小或其他改造(Kosslyn et al.,2006;Pearson,2007)。

以往的實驗認知研究主要關(guān)注非情緒性心理表象,近20年來,情緒性心理表象越來越受到研究重視。Holmes和Mathews(2010)強調(diào),心理表象與情緒之間存在“特殊關(guān)系”,心理表象對情緒與行為的作用不同于言語。心理表象被認為是情緒的“放大器”(Holmes,Geddes,Colom,&Goodwin,2008)或“強有力的驅(qū)動器”(Burnett Heyes et al.,2013)。研究證實,心理表象比言語對情緒的作用更大(Holmes,Lang,&Shah,2009;Lothmann,Holmes,Chan,&Lau,2011;Mathews,Ridgeway,&Holmes,2013),心理表象還能夠引導個體的目標行為(Libby,Shaeffer,Eibach,&Slemmer,2007)。

臨床與咨詢心理學研究尤其關(guān)注情緒障礙(emotional disorders)中的心理表象。情緒障礙并不是一種具體的精神障礙診斷類型,而是研究者對以情緒異常為主要癥狀的多種精神障礙的統(tǒng)稱(見Hackmann,Bennett-Levy,&Holmes,2011;Holmes&Mathews,2010;Koster,Fox,&MacLeod,2009;Williams et al.,2007),比如創(chuàng)傷后應激障礙(posttraumatic stress disorder,PTSD)、抑郁障礙(depressive disorders)、雙相障礙(bipolar disorders)、焦慮障礙(anxiety disorders)、強迫障礙(obsessive compulsive disorders)等。研究發(fā)現(xiàn),心理表象在大多數(shù)情緒障礙的癥狀發(fā)生、維持及治療中具有重要作用(Brewin,2014a;Brewin,Gregory,Lipton,&Burgess,2010;Hackmann et al.,2011;Holmes&Mathews,2010)。本文旨在介紹上述5類情緒障礙中的心理表象、基于心理表象對部分情緒障礙及癥狀的心理病理學解釋,以及針對或運用心理表象的干預與訓練方法。

2 情緒障礙中的心理表象

心理表象是人們?nèi)粘Ｐ睦砘顒拥闹匾矫?但痛苦的或無益的心理表象是許多情緒障礙的一個特點(Brewin,2014a;Brewin et al.,2010;Hackmann et al.,2011;Holmes&Mathews,2010)。不過,由于患者一般不會主動報告其癥狀中的心理表象,目前在精神障礙的診斷中并未對它廣泛重視。比如,《精神障礙診斷與統(tǒng)計手冊(第5版)》(Diagnostic and StatisticalManualof Mental Disorders,5th ed.;DSM-5;American Psychiatric Association,2013)只在PTSD、急性應激障礙(acute stress disorder,ASD)和強迫障礙的診斷標準中涉及反復發(fā)生的侵入性(intrusive)表象。

現(xiàn)有的研究主要關(guān)注情緒障礙患者的侵入性表象、有意記憶的表象特點、未來表象,以及表象加工能力。

2.1 侵入性表象

閃回(flashback)是PTSD的一個標志性癥狀(Brewin,2014a,2014b;Holmes&Mathews,2010;Kvavilashvili,2014),是最早被關(guān)注且研究最多的一種侵入性表象。研究發(fā)現(xiàn),幾乎所有中度至重度的PTSD患者都報告反復發(fā)生的閃回(Brewin,2014a;Brewin et al.,2010;Parry&O’Kearney,2014),其特點是侵入性的或非自愿的(involuntary),不受意識控制。閃回的內(nèi)容是過去的創(chuàng)傷事件(如死亡、被侵犯等)的片段或碎片(American Psychiatric Association,2013;Birrer,Michael,& Munsch,2007),包含生動的(vivid)感知覺特征,其中主要是視覺表象(Birrer et al.,2007;Parry&O’Kearney,2014)。閃回通常由內(nèi)外情境線索觸發(fā),患者如“時間旅行”般再次經(jīng)歷創(chuàng)傷事件(即當下再體驗),但缺乏時間與背景信息(Brewin,2014a;Brewin et al.,2010;Parry&O’Kearney,2014)。并且, 閃回常伴有強烈的痛苦情緒,主要包括害怕、悲傷、憤怒、無助等(Birrer et al.,2007;Brewin et al.,2009,2010);大部分閃回包含痛苦情緒的高峰時刻,也稱為“熱點”(hotspot)(Grey&Holmes,2008;Holmes,Grey,&Young,2005)。

除PTSD外,其他情緒障礙患者大部分也報告與過去創(chuàng)傷事件或消極事件有關(guān)的、令人痛苦的侵入性表象,包括抑郁障礙(Watson,Berntsen,Kuyken,&Watkins,2012;We?lau&Steil,2014)、雙相障礙(Gregory,Brewin,Mansell,&Donaldson,2010)、焦慮障礙(Hirsch&Holmes,2007;Moscovitch,Gavric,Merrifield,Bielak,&Moscovitch,2011;Ng,Abbott,&Hunt,2014;Pictet,2014)和強迫障礙(Lipton,Brewin,Linke,&Halperin,2010)。但這些患者報告的侵入性表象與PTSD的閃回在整體數(shù)量、內(nèi)容、感知覺特征、情緒體驗、當下感、分離體驗等方面有所不同(Birrer et al.,2007;Parry&O’Kearney,2014;We?lau&Steil,2014), 因此一些學者建議閃回只適用于PTSD(Brewin,2014b;Kvavilashvili,2014)。另外,情緒障礙患者往往消極評價并極力回避與過去創(chuàng)傷事件或消極事件有關(guān)的侵入性表象(含閃回)(Brewin,2014a;Brewin et al.,2010;Watson et al.,2012;Williams&Moulds,2008)。

除了與過去創(chuàng)傷事件或消極事件有關(guān)的侵入性表象外,許多情緒障礙患者還報告了即將發(fā)生的事件或未來事件的侵入性表象。研究發(fā)現(xiàn),PTSD患者常常抑制不住地對現(xiàn)實生活進行災難性想象(如疾病、死亡)(Hinton,Nickerson,&Bryant,2011);許多抑郁障礙患者頭腦中出現(xiàn)有關(guān)未來自殺的侵入性表象,也被稱作閃前(flashforward),其情緒體驗同時是痛苦的和舒適的(Crane,Shah,Barnhofer,&Holmes,2012;Hales,Deeprose,Goodwin,&Holmes,2011);雙相障礙患者關(guān)于未來的侵入性表象最多(Holmes et al.,2011),包括抑郁狀態(tài)的閃前(Hales et al.,2011)以及躁狂狀態(tài)下反復出現(xiàn)生動且愉悅的表象(Hales et al.,2011;Gregory et al.,2010;Ivins,Di Simplicio,Close,Goodwin,&Holmes,2014);許多焦慮障礙患者常常抑制不住地想象將要發(fā)生的消極(甚至是災難性的)情境及后果,如社交焦慮患者想象自己的焦慮癥狀(如臉紅、流汗)被人所見(Clark et al.,2006)、廣場恐懼癥患者想象即將發(fā)生的身心災難(Day,Holmes,&Hackmann,2004)、蜘蛛恐懼癥患者想象可怕蜘蛛來襲(Pratt,Cooper,&Hackmann,2004)、健康焦慮患者則想象自己將遭遇嚴重疾病或死亡及其可怕后果(Muse,McManus,Hackmann,Williams,&Williams,2010);一些強迫障礙患者常常抑制不住地想象即將出現(xiàn)令自己恐懼的事物或情境(如污染、危險或災難),從而引發(fā)強迫行為(Keen,Brown,&Wheatley,2008)。

2.2 有意記憶的表象特點

與健康人群相比,情緒障礙患者往往以第三人稱視角或觀察者視角回憶過去的情緒性事件,消極表象多于積極表象,并且更缺乏積極表象(Moscovitch et al.,2011;Watson et al.,2012)。另外,抑郁障礙患者更多采用第三人稱視角回憶過去的積極事件而不是消極事件(Nelis,Debbeer,Holmes,&Raes,2013)。

研究還發(fā)現(xiàn),PTSD患者(Brewin,2014a;Brewin et al.,2010)、抑郁障礙患者(Williams et al.,2007)和雙相障礙患者(Tzemou&Birchwood,2007)對過去情緒性事件的記憶過度概化(overgeneral),缺乏包含感知細節(jié)的具體表象。

2.3 未來表象

現(xiàn)有的研究并未涉及各類情緒障礙患者的未來表象。研究發(fā)現(xiàn),抑郁程度與想象積極未來事件的生動性(vividness)之間負相關(guān)(Blackwell et al.,2013),抑郁障礙患者生動想象未來的能力受損(Werner-Seidler&Moulds,2011)。與健康人群相比,抑郁障礙和焦慮障礙患者對積極未來事件的想象生動性以及發(fā)生可能性的主觀估計更低(Morina,Deeprose,Pusowski,Schmid,&Holmes,2011);雙相障礙患者對消極未來事件的想象更生動(Holmes et al.,2011)。焦慮障礙患者對消極未來事件的想象生動性以及發(fā)生可能性的主觀估計高于健康人群和抑郁障礙患者(Morina et al.,2011)。

2.4 表象加工能力

現(xiàn)有的研究并未涉及各類情緒障礙患者的表象加工能力。研究發(fā)現(xiàn),與健康人群相比,PTSD患者的表象轉(zhuǎn)換能力受損,他們在表象轉(zhuǎn)換測驗中表現(xiàn)糟糕(Gilbertson et al.,2007);抑郁障礙患者表象生成所需時間更長但表象保持時間無差異(Cocude,Charlot,&Denis,1997),并且心理旋轉(zhuǎn)所需時間更長(Rogers et al.,2002);雙相障礙患者的表象運用能力更高(Holmes et al.,2008,2011),但視覺空間加工能力受損(Pan,Hsieh,&Liu,2011);焦慮障礙患者對中性刺激的表象生成能力不足(Morrison,Amir,&Taylor,2011)。

2.5 小結(jié)

表1總結(jié)了5類情緒障礙中的心理表象特點。

從PTSD的閃回開始,研究者在許多情緒障礙中陸續(xù)發(fā)現(xiàn)了其他類型的病理性或異常的心理表象。圖1在心理表象的時間屬性(有關(guān)過去和有關(guān)未來)和情緒效價(積極和消極)兩個維度所構(gòu)成的象限上歸納了4類主要的病理性心理表象：(1)生動的侵入性表象(即包含豐富的感知細節(jié)),包括與過去創(chuàng)傷事件或消極事件有關(guān)的、令人痛苦的侵入性表象,以及與未來有關(guān)的、令人痛苦和/或愉悅的侵入性表象;(2)對消極未來事件的生動想象;(3)不生動的表象(即缺乏感知細節(jié)),包括與過去情緒性事件有關(guān)的、不生動的消極表象,以及對積極未來事件的想象不生動;(4)與過去情緒性事件有關(guān)的積極表象不生動且更缺乏。

表1 5類情緒障礙中的心理表象特點

圖1 病理性心理表象

3 基于心理表象的心理病理學解釋

目前,臨床與咨詢心理學研究者主要從認知行為理論取向來解釋情緒障礙及其病理性心理表象。

3.1 對PTSD及閃回的解釋

3.1.1 PTSD的認知模型

PTSD的認知模型(cognitive model of PTSD;Ehlers&Clark,2000)認為,閃回是最初的創(chuàng)傷事件沒有得到充分語境化(contextualization)加工的感知覺信息,由于對創(chuàng)傷事件相關(guān)或相似刺激的知覺啟動增強,導致與創(chuàng)傷有關(guān)的表象及情緒體驗容易被直接觸發(fā)。許多研究證實了閃回與知覺啟動增強之間的關(guān)系(Ehlers,Mauchnik,&Handley,2012;Ehring&Ehlers,2011;Lyttle,Dorahy,Hanna,&Huntjens,2010)。

另外,該模型還強調(diào)消極認知、認知與行為的保護性策略(如回避、壓抑)對癥狀維持的作用。研究發(fā)現(xiàn),個體對創(chuàng)傷事件的消極評價、對最初癥狀的消極解釋、對創(chuàng)傷后其他人反應的消極解釋,都能夠預測PTSD的維持(Ehlers&Clark,2000;Regambal&Alden,2009);個體嘗試改變消極認知和創(chuàng)傷記憶的努力通常被認知與行為的保護性策略所阻止(Ehlers&Clark,2000;Regambal&Alden,2009),從而維持了癥狀。

3.1.2 自我記憶系統(tǒng)模型對閃回的解釋

自傳體記憶(autobiographical memory,AM)是指與自我及個人史有關(guān)知識的特定記憶子集(Baddeley,2001)。自我記憶系統(tǒng)模型(self-memory system model;Conway&Pleydell-Pearce,2000)認為,AM是連續(xù)多層的,包含感知細節(jié)的具體情景記憶在AM中層級最低或具體性最高,既可以有意地、自上而下地生成提取(generative retrieval),也可以由內(nèi)外情境線索觸發(fā)、自下而上地直接提取(direct retrieval)。閃回被認為是具體情景記憶的直接提取,是缺少概念性語境知識框架的情景記憶成分在意識中的侵入(Conway,2009)。

3.1.3 PTSD的雙重表征理論對閃回的解釋

PTSD的雙重表征理論(dual representation theory of PTSD,DRT)支持多重記憶系統(tǒng)的觀點,最初由Brewin及其同事提出(Brewin,2001;Brewin,Dalgleish,&Joseph,1996)。后來,研究者依據(jù)正常記憶與心理表象的神經(jīng)生物學模型對DRT進行了修正(Brewin et al.,2010),用以解釋侵入性視覺表象(即閃回)的形成與提取。以下簡單介紹修正的DRT(如圖 2)。

圖2 DRT簡單示意圖

DRT提出存在相互獨立、相互影響的兩個記憶系統(tǒng)：(1)語境記憶(contextual memory,C-memory),采用語境表征(C-rep),沿視覺加工腹側(cè)通路(主要包括感覺聯(lián)合區(qū)域、海馬、海馬旁回);(2)基于感覺的記憶(sensation-based memory,S-memory),采用感覺表征(S-rep),沿視覺加工背側(cè)通路(主要包括早期感覺皮層和皮層下區(qū)域、杏仁核、腦島)。個體遭遇生活事件時,正常的編碼過程是C-rep和S-rep同時進行,且相互聯(lián)接。但由于高水平應激損害海馬功能,同時卻增強杏仁核功能(Vyas,Mitra,Shankaranarayana Rao,&Chattarji,2002),導致個體對創(chuàng)傷事件進行病理性編碼,具體表現(xiàn)為：S-rep上調(diào)(增強),C-rep下調(diào)(減弱),且二者失聯(lián)。當個體有意提取正常的視覺性記憶時,視覺表象在前額葉皮層的指導下由C-rep自上而下驅(qū)動,而S-rep的再激活減弱(S-rep的再激活取決于個體注意到與表象相匹配的感知細節(jié))。創(chuàng)傷事件的非自愿閃回則表現(xiàn)為：視覺表象由S-rep自下而上驅(qū)動,由內(nèi)外情境線索觸發(fā),并且不受微弱激活的C-rep影響。

3.2 CaR-FA-X模型對過度概化記憶的解釋

CaR-FA-X模型(Williams et al.,2007)主要用于解釋情緒障礙患者對過去消極事件的記憶過度概化。該模型基于自我記憶系統(tǒng)模型(Conway&Pleydell-Pearce,2000),認為過度概化記憶是一種認知保護機制,使個體回避提取過去消極事件的具體情景記憶,從而減少痛苦(至少是暫時減少)。該模型認為,過度概化記憶是由于對具體情景記憶的生成提取過程過早中止,主要有3種加工影響提取過程：(1)CaR：俘獲(capture)與反芻(rumination)加工,與自我相關(guān)的概念信息激活反芻加工(即關(guān)于癥狀及其原因和后果的反復性被動思考),從而俘獲了有限的認知資源;(2)FA：功能性回避(functional avoidance)是對過去消極事件的反應,是一種自我保護的情緒調(diào)節(jié)方法;(3)X：執(zhí)行控制受損(impaired executive capacity and control)不僅限制了成功提取的能力,也限制了提取過程所能使用的認知資源。過度概化記憶既受到這3種加工的單獨影響,還可能受到三者交互作用的影響(如圖3)。該模型得到了許多研究的支持,但目前仍然不清楚這3種加工的影響程度以及它們之間如何交互作用(Sumner,2012)。

圖3 CaR-FA-X模型(Williams et al.,2007)

3.3 對抑郁心境的解釋

3.3.1 抑郁的實驗心理病理子成分模型

抑郁的實驗心理病理子成分模型(experimental psychopathology subcomponents model of depression;Holmes,Lang,&Deeprose,2009)認為,抑郁心境的維持與加重受到(1)消極表象,(2)缺乏積極表象,以及(3)消極解釋偏差等3種心理病理子成分的單獨影響,以及三者交互作用的影響(如圖4)。

圖4 抑郁的實驗心理病理子成分模型(Holmes,Lang,&Deeprose,2009)

3.3.2 表象在抑郁心境維持中的作用

We?lau和Steil(2014)也關(guān)注表象在抑郁心境維持中的作用。他們認為,消極表象、缺乏積極表象、有關(guān)自殺或自傷的閃前對抑郁心境的維持具有重要作用。抑郁心境的維持與加重是因為存在這樣一個惡性循環(huán)：負性生活事件與功能失調(diào)的應對策略(如壓抑、回避)相結(jié)合造成了消極表象以及隨后的抑郁心境,接下來導致更多的反芻加工和侵入性記憶(含表象),它們反過來又影響抑郁心境。

3.4 心理表象對雙相障礙情緒的作用模型

該模型(Holmes et al.,2008)強調(diào)心理表象對情緒的放大作用,關(guān)注消極表象對雙相障礙患者焦慮的作用,以及積極表象對躁狂的作用(如圖5)。

3.5 社交焦慮的表象模型

心理表象對于社交焦慮或社交恐懼的維持具有關(guān)鍵作用(Clark et al.,2006;Hirsch&Holmes,2007;Pictet,2014)。社交焦慮者常常設想即將發(fā)生的社交情境的細節(jié),其消極自我表象被激活;一旦進入社交情境,他們傾向于自我關(guān)注,并根據(jù)相關(guān)的消極表象判斷自己的行為表現(xiàn),而這些消極表象容易被軀體癥狀(如臉部溫度上升)所強化(如臉看上去非常紅),因而更加焦慮;離開社交情境后,他們對自己的行為表現(xiàn)進行反芻加工,消極表象也再次被激活。消極表象讓他們相信自己又失敗了,進而繼續(xù)影響今后的社交行為。

3.6 小結(jié)

上述心理病理學解釋主要涉及PTSD、抑郁心境、雙相障礙情緒(焦慮和躁狂)、社交焦慮,尤其關(guān)注閃回和過度概化記憶等兩種典型癥狀,重視心理表象在情緒癥狀維持中的作用。目前,對于其他情緒障礙及癥狀,研究者尚未從心理表象的視角形成較為系統(tǒng)的理論解釋模型,但重視心理表象對異常情緒與行為的作用(Brewin,2014a;Brewin et al.,2010;Hackmann et al.,2011;Holmes&Mathews,2010)。

圖5 心理表象對雙相障礙情緒的作用模型：表象放大焦慮和躁狂(Holmes et al.,2008)

另外,從上述心理病理學解釋可以看出,研究者強調(diào)了以下三類因素對情緒障礙的致病作用：⑴記憶形成與提取過程的異常,如S-rep增強但C-rep減弱以及二者失聯(lián)、知覺啟動增強、具體情景記憶的生成提取過早中止;⑵認知與行為的保護性策略的負強化,如回避、壓抑;⑶對事件及自我的認知偏差,如對事件的消極評價和消極解釋、消極自我表象。因此,在情緒障礙的心理咨詢與治療中,可以將這三類因素作為主要的干預與訓練對象或靶子。

4 針對或運用心理表象的干預與訓練方法

在各流派的心理咨詢與治療實踐中,幾乎都涉及心理表象(比如讓當事人描述記憶和想象)。目前,認知行為取向的治療家和研究者發(fā)展出一些針對或運用心理表象的、較為系統(tǒng)的干預與訓練方法或技術(shù),它們有的已應用于臨床實踐,有的尚處于模擬研究階段。

4.1 減少消極表象(含侵入性表象)

這一類干預與訓練方法主要針對認知與行為的保護性策略的負強化、記憶形成與提取過程的異常。

4.1.1 想象暴露(imaginal exposure,IE)

IE是認知行為療法中常見的一種技術(shù)(比如系統(tǒng)脫敏療法、暴露療法)。IE旨在減少回避對癥狀的負強化作用,讓當事人重新經(jīng)歷自己一直試圖回避的、生動而痛苦的心理表象,從而逐漸對觸發(fā)線索習慣化(即減少消極表象的出現(xiàn)),并且對消極表象脫敏(即減少消極表象帶來的負性情緒)。并且,IE還有助于C-rep和S-rep的聯(lián)接與整合(Brewin et al.,2010)。研究表明,IE能夠有效減少侵入性表象(Ehlers et al.,2012;Powers,Halpern,Ferenschak,Gillihan,&Foa,2010)、惡夢(Hansen,H?fling,Kr?ner-Borowik,Stangier,&Steil,2013),并緩解抑郁(Klainin-Yobas,Cho,&Creedy,2012)和PTSD癥狀(Hansen et al.,2013;Mota et al.,2015;Powers et al.,2010)。需要注意的是,IE帶來的情緒痛苦可能會讓某些當事人提前中止治療。

4.1.2 正念(mindfulness)

基于正念的認知療法(mindfulness-based cognitive therapy,MBCT)主張接納內(nèi)在經(jīng)驗(包括想法、表象、感受),并區(qū)分認知(心理事件)與客觀事實(Segal,Williams,&Teasdale,2012)。通過接納訓練,減少認知回避及壓抑的負強化作用,并減少認知的誤導作用。研究表明,MBCT能夠有效減少抑郁及其復發(fā)(Chiesa&Serretti,2011;Piet&Hougaard,2011),也能夠減少焦慮(Chiesa&Serretti,2011)和自殺意念(Forkmann et al.,2014);另一種正念訓練——觀呼吸,能夠減少回憶消極事件時的表象生動性和負性情緒(van den Hout,Engelhard,Beetsma et al.,2011)。

4.1.3 競爭性/干擾性任務

首先,眼動(eye movement)能夠影響記憶及其有關(guān)情緒。有計劃的眼動(水平方向)是眼動脫敏和再加工(eye-movement desensitization and reprocessing,EMDR)的主要技術(shù),能直接調(diào)整記憶與表象的形成,在記憶再加工過程中促進C-rep和S-rep的聯(lián)接與整合(Brewin et al.,2010),并通過占用工作記憶的有限認知資源而影響記憶再加工(Gunter&Bodner,2008)。研究發(fā)現(xiàn),在頭腦中保持記憶和表象的同時進行眼動,既能夠減少消極記憶的表象生動性和情緒性(Engelhard,van Uijen,&van den Hout,2010;Gunter&Bodner,2008;Leer,Engelhard,&van den Hout,2014;van den Hout,Engelhard,Beetsma et al.,2011;van den Hout,Engelhard,Rijkeboer et al.,2011),也能夠減少積極記憶的表象生動性和情緒性(Engelhard et al.,2010),還能減少未來侵入性表象的生動性(Engelhard,van den Hout,Dek et al.,2011)。Lee和 Cuijpers(2013)的元分析發(fā)現(xiàn),眼動對于消極記憶生動性和負性情緒的減少作用在臨床樣本中效應量中等,在非臨床樣本中效應量大(尤其是減少表象生動性)。

其次,除眼動外,還有一些針對消極記憶的其他干擾性任務。研究發(fā)現(xiàn),在頭腦中保持記憶和表象的同時進行言語或非言語任務也能夠減少記憶生動性和/或負性情緒。比如,倒數(shù)(Engelhard,van den Hout,&Smeets,2011;van den Hout et al.,2010)、簡單發(fā)音(Gunter&Bodner,2008)、俄羅斯方塊游戲(Engelhard et al.,2010)、在頭腦中復印幾何圖形(Gunter&Bodner,2008)、輪流注意雙側(cè)聲音(van den Hout,Engelhard,Rijkeboer et al.,2011)。

第三,一些競爭性認知任務能夠干擾創(chuàng)傷記憶形成。研究發(fā)現(xiàn),在記憶形成過程中,同時進行的表象任務能夠干擾工作記憶中相應的表象加工,甚至影響相應的長時記憶(Baddeley&Andrade,2000;Borst,Ganis,Thompson,&Kosslyn,2012)。根據(jù)DRT,在侵入性表象的形成過程中,同時進行的視覺空間任務競爭視覺加工背側(cè)通路的認知資源,因此具有干擾作用(Brewin,2014a;Brewin et al.,2010)。在健康人群中的一些模擬創(chuàng)傷研究證實了該觀點(Bourne,Frasquiho,Roth,&Holmes,2010;Brewin,2014a;Krans,N?ring,Holmes,&Becker,2010a,2010b;Logan&O’Kearney,2012;Pearson&Sawyer,2011)。并且,在記憶鞏固時間窗6小時(Nader,2003;Walker,Brakefield,Hobson,&Stickgold,2003)以內(nèi)進行的視覺空間任務也具有干擾作用。研究發(fā)現(xiàn),觀看創(chuàng)傷性影片后立即進行(Deeprose,Zhang,DeJong,Dalgleish,&Holmes,2012)以及半小時后進行的視覺空間任務(Deeprose et al.,2012;Holmes,James,Cood-Bate,&Deeprose,2009;Holmes,James,Kilford,&Deeprose,2010),甚至是4小時后進行的視覺空間任務(Holmes et al.,2010),都能夠減少實驗后1周內(nèi)的侵入性表象。另外,由于占用工作記憶的有限認知資源,同時進行的言語分心任務也能夠抑制個體對消極情緒信息或創(chuàng)傷信息的加工(竇偉偉等,2014;van Dillen&Derks,2012)。研究發(fā)現(xiàn),健康被試觀看創(chuàng)傷性圖片同時進行的言語任務能夠減少實驗后1周內(nèi)的侵入性表象(Krans,Langner,Reinecke,&Pearson,2013;Pearson&Sawyer,2011)。

4.1.4 提高語境化加工

在健康人群中的模擬研究發(fā)現(xiàn),被試觀看創(chuàng)傷性圖片后回答與實驗過程有關(guān)的問題(如圖片內(nèi)容以及實驗中的情緒與想法)(Ehlers et al.,2012),以及觀看創(chuàng)傷性影片后的再認測試(Krans,N?ring,Holmes,&Becker,2009),都能夠減少實驗后1周內(nèi)的侵入性表象。

4.1.5 改變加工視角

采用第三人稱視角想象和回憶能夠減少情緒性(Berntsen&Rubin,2006),盡管被看作是與情緒障礙維持有關(guān)的、回避消極情緒的暫時性保護策略,但也有助于改變患者的反芻加工。研究發(fā)現(xiàn),訓練輕度抑郁的非臨床患者采用第三人稱視角加工消極的侵入性記憶,能夠減少痛苦感和當下感(Williams&Moulds,2008);訓練抑郁障礙患者采用自我距離(self-distance)的方式分析自身消極感受,并不會增加回避,反而能夠減少有關(guān)的消極想法,促進領(lǐng)悟(Kross,Gard,Deldin,Clifton,&Ayduk,2012)。

4.2 改變消極表象內(nèi)容

表象再編(imagery rescripting,IR)訓練主要針對記憶提取過程的異常、對事件及自我的認知偏差。IR是指“對令人厭惡的經(jīng)驗的記憶或幻想之中的事件過程進行想象改變”(Arntz,2012),這種想象中的積極重構(gòu)有助于改變消極認知圖式(Arntz,2012;We?lau&Steil,2014)。IR 的作用原理還可以用“提取競爭假說”(Brewin,2006)來解釋,即經(jīng)過加強練習的積極表象可及性(accessibility)更高,在記憶提取時比消極表象更受青睞(Brewin et al.,2009,2010)。

臨床樣本的研究證實了IR的干預效果。比如,IR能夠改善PTSD癥狀(Jung&Steil,2013;Raabe,Ehring,Marquenie,Olff,&Kindt,2015),緩解抑郁(Brewin et al.,2009;Rahnama,Tarkhan,&Khalatbari,2013)、社交焦慮(Frets,Kevenaar,&van der Heiden,2014;McEvoy,Erceg-Hurn,Saulsman,&Thibodeau,2015)以及強迫(Veale,Page,Woodward,&Salkovskis,2015),甚至減少兒童的恐懼(Raby&Edwards,2011)和重復性惡夢(St-Onge,Mercier,&De Koninck,2009)。此外,IR還能夠影響PTSD的形成,健康被試觀看創(chuàng)傷性影片后的IR訓練能夠減少實驗后1周內(nèi)的侵入性表象(Hagenaars&Arntz,2012)。

4.3 提高積極表象能力

這一類訓練方法主要針對個體對事件的認知偏差。由于個體的想法和視覺表象都是認知(Beck,Rush,Shaw,&Emery,1979),改變與表象有關(guān)的認知偏差有助于提高個體積極表象的能力(Hertel&Mathews,2011;MacLeod&Holmes,2012;MacLeod&Mathews,2012;Pictet,2014)。認知偏差矯正(cognitive bias modification,CBM)是一種計算機化訓練程序,通過系統(tǒng)訓練積極的認知加工方式來改變個體的消極認知偏差(Koster et al.,2009;Woud&Becker,2014)。目前,CBM在許多情緒障礙的治療中逐步推廣。

4.3.1 注意偏向矯正(CBMforattention bias,CBM-A或attention bias modification,ABM)

CBM-A是最早出現(xiàn)的CBM,主要通過反復訓練個體注意積極信息(如積極表情圖片),促進形成積極注意偏向(可參考 王曼,陶嶸,胡姝婧,朱旭,2011;趙鑫,張鵬,陳玲,2014;MacLeod&Clarke,2015)。研究發(fā)現(xiàn),CBM-A有助于改善抑郁(Browning et al.,2011;Browning,Holmes,Charles,Cowen,&Harmer,2012;Clasen,Wells,Ellis,&Beevers,2013)、焦慮(Browning et al.,2011;Eldar et al.,2012;Hallion&Ruscio,2011)、強迫(Najmi&Amir,2010)和恐懼(Reese,McNally,Najmi,&Amir,2010)。

此外,由于對情緒性刺激(積極或消極)的趨向與回避影響個體的情緒與行為(Browning,Holmes,Murphy,Goodwin,&Harmer,2010;Wiers,Gladwin,Hofmann,Salemink,&Rindderinkhof,2013),一些研究者在CBM-A的基礎上研發(fā)了“趨向—回避矯正”(CBM for approach-avoidance,CBM-AA)(Asnaani,Rinck,Becker,&Hofmann,2014)。但研究發(fā)現(xiàn),CBM-AA對社交焦慮只有短暫效果,不能促進行為改變和焦慮緩解(Asnaani et al.,2014)。

4.3.2 解釋偏差矯正(CBM for interpretation bias,CBM-I)

CBM-I最初由Mathews和Mackintosh(2000)研發(fā),受訓者根據(jù)情緒性情境的文字描述或錄音(情境結(jié)果最初不明確但最后呈現(xiàn)積極結(jié)果)進行反復的想象訓練(Hertel&Mathews,2011;MacLeod&Mathews,2012),促進形成積極解釋偏向(Fu,Du,Au,&Lau,2013;Joormann,Waugh,&Gotlib,2015),還能改變記憶偏差(Joormann et al.,2015;Tran,Hertel,&Joormann,2011)。研究發(fā)現(xiàn),CBM-I有助于改善抑郁(Bowler et al.,2012;Holmes,Lang,&Shah,2009;Torkan et al.,2014)、焦慮(Bowler et al.,2012;Hoppitt et al.,2014;Lau&Pile,2015;Lothmann et al.,2011)和強迫(Clerkin&Teachman,2011;Williams&Grisham,2013)。

此外,一些研究者致力于改進標準的CBM-I(即上述采用情緒性情境材料的訓練程序)。比如,在CBM-I中運用評價性條件反射(evaluative conditioning,EC)范式,訓練個體根據(jù)不同情緒效價的詞匯對意義不明的圖片進行想象(Mathews et al.,2013);有的研究者還通過感知相機(SenseCam)從受訓者日常生活中采集照片作為訓練材料(Murphy,Barnard,Terry,Carthery-Goulart,&Holmes,2011)。研究發(fā)現(xiàn),運用EC范式改進的CBM-I有助于改善抑郁(Pictet,Coughtrey,Mathews,&Holmes,2011)。另外,Yiend及其同事在CBM-I的基礎上研發(fā)了“認知錯誤矯正”(CBM for cognitive errors,CBM-errors),訓練個體形成積極推理和積極解釋偏向(Lee et al.,2015;Yiend et al.,2014)。

4.3.3 評價偏差矯正(CBM for appraisal bias,CBM-App)

CBM-App用以矯正個體對侵入性記憶的消極評價。在健康人群中的模擬創(chuàng)傷研究發(fā)現(xiàn),CBM-App有助于被試對侵入性記憶形成更加積極的評價(Woud,Postma,Holmes,&Mackintosh,2013),并且減少觀看創(chuàng)傷性影片后的侵入性表象(Schartau,Dalgleish,&Dunn,2009;Woud,Holmes,Postma,Dalgleish,&Mackintosh,2012)以及由侵入性記憶引起的負性情緒(Woud et al.,2013);CBM-App還有助于個體更少回避過去的消極記憶(Schartau et al.,2009)。另外,對非臨床抑郁個體的研究發(fā)現(xiàn),CBM-App有助于緩解與侵入性記憶有關(guān)的負性情緒(Newby,Lang,Werner-Seidler,Holmes,&Moulds,2014)。

4.3.4 CBM的組合

為了減少單一CBM訓練的枯燥性,提高訓練效果,一些研究者探討不同CBM的組合。研究發(fā)現(xiàn),CBM-A和CBM-I組合能夠改善社交焦慮(Beard,Weisberg,&Amir,2011),標準的CBM-I和運用EC范式改進的CBM-I組合能夠改善抑郁(Blackwell et al.,2015),標準的CBM-I、運用EC范式改進的CBM-I和CBM-App組合也能夠改善抑郁(Lang,Blackwell,Harmer,Davison,&Holmes,2012)。

此外,CBM-I結(jié)合基于互聯(lián)網(wǎng)的認知行為療法(internet-based cognitive behavioral therapy,iCBT)也能夠改善抑郁(Williams,Blackwell,Mackenzie,Holmes,&Andrews,2013;Williams et al.,2015)。

4.4 提高記憶的具體性

這一類訓練方法主要針對記憶提取過程的異常,旨在減少過度概化記憶。通過訓練提高記憶的具體性有益于抑郁及其他情緒障礙(Dalgleish&Werner-Seidler,2014)。研究發(fā)現(xiàn),針對消極記憶進行具體性訓練,有助于改善非臨床抑郁個體(Watkins,Baeyens,&Read,2009)和抑郁障礙患者(Watkins et al.,2012;Werner-Seidler&Moulds,2012)的抑郁癥狀,提高記憶的具體性;運用古老的記憶增強術(shù)——軌跡法(method-of-loci,MoL)進行1周的積極記憶訓練,能夠提高抑郁障礙患者有關(guān)情緒性記憶的具體性(Dalgleish et al,2013)。

另外,記憶具體性訓練(memory specificity training,MEST)是一套為期4周的團體訓練,能夠提高抑郁障礙患者記憶的具體性(Neshat-Doost et al.,2013;Raes,Williams,&Hermans,2009),改善抑郁癥狀(Neshat-Doost et al.,2013);也能夠提高PTSD患者記憶的具體性,改善PTSD癥狀(Moradi et al.,2014)。

5 評論與展望

基于心理表象的視角探討情緒障礙及其干預,是一個極具前景的研究領(lǐng)域?，F(xiàn)有的研究主要從認知行為理論取向開展,豐富了臨床與咨詢心理學有關(guān)情緒障礙癥狀學、心理病理學以及干預的知識。除了繼續(xù)拓展癥狀學領(lǐng)域的研究,未來的研究還需要注意以下問題：

5.1 侵入性表象的功能分析

癥狀的功能往往與個人價值系統(tǒng)(如生存、滿足需要、調(diào)節(jié)情緒)有關(guān),主要體現(xiàn)為強化作用,是癥狀維持的一個重要因素。侵入性表象是各種情緒障礙的共有癥狀,現(xiàn)有的研究主要關(guān)注其特點(如感知覺特征、內(nèi)容或主題、情緒等),但較少關(guān)注其功能。目前,對侵入性表象的功能分析僅涉及PTSD的閃回,以及抑郁障礙和雙相障礙的閃前。閃回的功能包括為創(chuàng)傷事件的情緒加工提供相關(guān)信息、作為避免將來傷害的預警信號、保護自我的連貫性(coherence),其他侵入性表象也可能如此(Krans,N?ring,Becker,&Holmes,2009)。而抑郁障礙與雙相障礙患者有關(guān)自殺的閃前、雙相障礙患者躁狂狀態(tài)下的閃前均伴隨愉悅和舒適的情緒體驗,可能體現(xiàn)了閃前滿足需要、調(diào)節(jié)情緒的功能。但是,其他障礙中的侵入性表象目前并未得到足夠的研究關(guān)注,關(guān)于它們的功能也沒有研究證據(jù)。另外,健康個體也有侵入性表象(Kvavilashvili,2014),病理性表象與正常表象在特點上有所不同(如頻率、情緒、對日常生活的干擾),但二者在功能上的異同尚不明確。因此,今后有必要開展深入的質(zhì)性研究,了解病理性表象的共有功能,以及不同侵入性表象的特異性功能。比如,對過去未竟事件的情緒宣泄或想象解決可能是正常表象的功能,對危險的預警信號作用可能是令人痛苦的、有關(guān)過去和未來的病理性表象的共有功能,解脫則可能是有關(guān)自殺的閃前的一種特異性功能。

5.2 心理病理學模型的研究

目前,基于心理表象的心理病理學模型主要涉及PTSD、抑郁心境、雙相障礙情緒和社交焦慮,重點關(guān)注閃回和過度概化記憶,強調(diào)心理表象在情緒癥狀維持中的作用。這些模型大都得到了研究支持,但仍需要深入的研究。比如,CaR-FA-X模型中3種加工的影響程度以及它們之間的交互作用(Sumner,2012);PTSD的認知模型和DRT則需要逐漸突破實驗室的模擬研究(Brewin,2014a)。還有一些模型目前仍存在爭議,比如DRT盡管得到了許多研究的支持(Brewin,2014a),但也有研究并不支持該理論(如竇偉偉等,2014;Engelhard,van den Hout,&Smeets,2011;Gunter&Bodner,2008;Krans et al.,2013;Pearson&Sawyer,2011;van den Hout et al.,2010),因此需要深入探討。

另外,有關(guān)PTSD的心理病理學模型側(cè)重認知加工過程,對個體特征關(guān)注不足。研究發(fā)現(xiàn),個體的一般表象能力(general ability to imagery)(Morina,Leibold,&Ehring,2013)、注意控制特質(zhì)(楊慧芳等,2013;Hagenaars&Putman,2011)、認知抑制能力(Benoit&Anderson,2012;Catarino,Küpper,Werner-Seidler,Dalgleish,&Anderson,2015;Küpper,Benoit,Dalgleish,& Anderson,2014)、空間構(gòu)型學習能力(Meyer et al.,2013)、語境化記憶能力(Glazer,Mason,King,&Brewin,2013)、價值觀(王建平,王玉龍,謝龍,楊智輝,2007)等與PTSD關(guān)系密切。因此,PTSD的模型有待進一步修正。

未來的研究還應致力于發(fā)展其他情緒障礙及其病理性表象的心理病理學模型。比如,目前對侵入性表象的解釋僅限于PTSD的閃回,但其他障礙的侵入性表象與閃回不同,而且不同障礙的侵入性表象也不同(如強迫障礙患者報告的侵入性表象不同于焦慮障礙患者;Lipton et al.,2010)。因此,可以嘗試參考有關(guān)模型并結(jié)合侵入性表象的功能分析而形成心理病理學解釋。

5.3 干預與訓練研究的拓展

許多針對或運用心理表象的干預與訓練方法注重結(jié)合當代認知心理學和神經(jīng)科學,符合心理治療的發(fā)展趨勢(Holmes,Craske,&Graybiel,2014),但仍需開展更多的臨床應用研究,尤其是尚處于模擬階段的干預方法。比如,減少消極表象的競爭性/干擾性任務需要深入的應用基礎研究,并逐漸走出實驗室模擬研究,提高生態(tài)效度。

有關(guān)CBM的臨床應用研究已廣泛開展,是當前臨床與咨詢心理學的一個研究熱點。CBM應用廣泛,除了情緒障礙,還被用于精神分裂癥(Levaux,Lar?i,Offerlin-Meyer,Danion,&van der Linden,2011)、物質(zhì)濫用與成癮(Wiers et al.,2013;Woud,Hutschemaeker,Rinck,&Becker,2015)、慢性疼痛(Baum,Schneider,Keogh,&Lautenbacher,2013),甚至可能有益于一些特殊人群(如自閉癥兒童)(趙鑫等,2014)。而且,CBM易于結(jié)合當代信息科技(如互聯(lián)網(wǎng)、智能手機),可以為公眾提供便捷低價的專業(yè)服務。未來的研究應致力于提高CBM的訓練效果尤其是長期效果(趙鑫等,2014),注重個體差異(如表象能力的個體差異、抑郁的亞型)、優(yōu)化訓練程序(Blackwell et al.,2015;Clarke et al.,2014;Fox,Mackintosh,&Holmes,2014;Rohrbacher,Blackwell,Holmes,&Reinecke,2014)。還有必要研發(fā)包含標準化測量工具的訓練軟件包,以便根據(jù)個體差異和主要訓練目標(即具體的消極認知偏差)開展針對性訓練(單一的或組合的CBM)。

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