The impact of imagery rescripting on memory appraisals and core beliefs in social anxiety disorder

The development of the Negative Mental Imagery Questionnaire (MIQ-N)

BACKGROUND

Mental imagery plays a key role in the onset and maintenance of psychological disorders, and has become the target of psychological interventions for the treatment of several anxiety-related conditions. However, there are currently no transdiagnostic measures designed to assess the varied dimensions of mental imagery relevant to psychopathology.

AIM

To develop and validate a new measure assessing the experiences and appraisals of negative mental imagery.

METHOD

The initial item pool was generated through a comprehensive literature review and interviews with subject-matter experts. An online community sample provided data for the exploratory (n=345) and confirmatory (n=325) factor analyses.

RESULTS

The new 16-item Negative Mental Imagery Questionnaire demonstrated four subscales (Intrusiveness, Controllability, Beliefs about Mental Imagery, and Realness). Reliability and validity were good to excellent for both the full- and sub-scales.

CONCLUSIONS

Appraisals of mental imagery captured by the new measure are consistent with previous research on mental imagery and psychopathology.

Experiences of imagery-based treatment for anxiety in bipolar disorder: A qualitative study embedded within the image based emotion regulation feasibility randomised controlled trial

OBJECTIVES

Intrusive mental imagery is associated with anxiety in bipolar disorder (BD) and presents a novel treatment target. Imagery-based treatments show promise in targeting anxiety and improving mood instability. This qualitative study explored experiences of receiving up to 12 sessions of a brief structured psychological intervention: Image-Based Emotion Regulation (IBER), which targets maladaptive mental imagery in the context of BD with an aim to modify the emotional impact of these images.

DESIGN

A qualitative study embedded within the Image Based Emotion Regulation (IBER) feasibility randomised controlled trial.

METHODS

Semi-structured interviews were conducted with 12 participants in the treatment arm of the trial who received IBER + treatment as usual. Data were analysed using thematic analysis.

RESULTS

Despite some initial scepticism about imagery-focused treatment, all participants expressed broadly positive accounts of treatment experiences. High levels of engagement with imagery modification techniques, beneficial use of techniques post treatment and improvements in anxiety management and agency were described by some. Three sub-groups were identified: those who reported a powerful transformative impact of treatment; those who embedded some new techniques into their daily lives, and those who felt they had techniques to use when needed. No participants reported overall negative experiences of the IBER treatment.

CONCLUSIONS

Findings from this study highlight the value for treatment recipients of modifying the underlying meanings associated with maladaptive imagery, and the personalised skills development to manage anxiety within bipolar disorders. Findings can inform treatment refinements and further trial-based evaluations.

Hooking the Self Onto the Past: How Positive Autobiographical Memory Retrieval Benefits People With Social Anxiety

Do people with social anxiety (SA) benefit from positive memory retrieval that heightens self-relevant meaning? In this preregistered study, an analog sample of 255 participants with self-reported clinically significant symptoms of SA were randomly assigned to retrieve and process a positive social-autobiographical memory by focusing on either its self-relevant meaning (deep processing) or its perceptual features (superficial processing). Participants were then socially excluded and instructed to reimagine their positive memory. Analyses revealed that participants assigned to the deep processing condition experienced significantly greater improvements than participants in the superficial processing condition in positive affect, social safeness, and positive beliefs about others during initial memory retrieval and in negative and positive beliefs about the self following memory reactivation during recovery from exclusion. These novel findings highlight the potential utility of memory-based interventions for SA that work by "hooking" self-meaning onto recollections of positive interpersonal experiences that elicit feelings of social acceptance.

Emotional Changes during Imagery Rescripting of Aversive Social Memories in Social Anxiety Disorder: A Randomized Controlled Trial

INTRODUCTION

Imagery rescripting (ImRs) is a psychotherapeutic intervention targeting aversive memories. During the three-phase intervention, patients reexperience their aversive memory (phase 1), observe the scene from their adult perspective, and intervene to help their former selves (phase 2), and reexperience it again with the positive changes (phase 3). Previous studies have rarely investigated emotional and regulatory processes taking place during the intervention.

OBJECTIVE

This randomized controlled trial investigated self-reported affective and physiological responses during ImRs.

METHODS

Seventy-seven patients with social anxiety disorder (SAD) were randomly assigned to a single session of ImRs or a control intervention (recall and discussion of the memory) targeting an aversive social memory. Heart rate (HR) and heart rate variability (HRV) were assessed during and post hoc ratings of positive and negative feelings after baseline and the intervention phases.

RESULTS

Relative to the control intervention, ImRs resulted in an initial increase in negative feelings from baseline to phase 1 and a following larger (phase 1 to phase 2) and more stable (phase 2 to phase 3) decrease in negative feelings/increase in positive feelings. On the physiological level, during ImRs compared to the control intervention, mean HR was significantly higher during phase 1 and HRV during phase 3, each compared to baseline.

CONCLUSIONS

These results provide further information about the specific sequence of emotional responses on different response levels during ImRs, being consistent with known theories of emotional processing and supposed mechanisms of ImRs.

The efficacy of psychotherapy for social anxiety disorder, a systematic review and meta-analysis

BACKGROUND

Given the growth in research examining the effects of psychotherapy on social anxiety disorder (SAD), an up-to-date comprehensive meta-analysis in this field is needed.

METHODS

We selected studies from a database of randomized trials (RCTs) on psychotherapies for anxiety disorders (last updated search of PubMed, PsycINFO, Embase, and Cochrane (CENTRAL): 1 January 2024) We included RCTs comparing psychotherapy to a control condition for adults with SAD and conducted random effects meta-analyses to examine the efficacy of psychotherapy compared to control conditions at post-treatment.

RESULTS

Sixty-six RCTs were included with 5560 participants and 98 comparisons between psychotherapy and control groups. Psychotherapy was effective in reducing SAD symptoms, with a large effect size (g = 0.88; 95 % CI: 0.76 to 1.0; I2 = 74 %; 95 % CI: 69 to 79, NNT = 3.8). Effects remained robust across sensitivity analyses. However, there was evidence for significant risk of bias in the included trials. The multivariable meta-regression indicated significant differences in treatment delivery formats, type of recruitment strategy, target group, and number of sessions.

CONCLUSION

Psychotherapy is an effective treatment for SAD, with moderate to large effect sizes across all treatment types and formats. Future research is needed to determine the long-term effects.

Self-guided imagery rescripting for worry images: A preliminary experimental investigation

BACKGROUND

Mental images of feared events are overactive and intrusive in generalized anxiety disorder (GAD). Imagery rescripting involves integration of positive or neutral imagery and corrective information into images to facilitate emotional processing, reduce imagery intrusions, and re-structure underlying schema. Yet only one known study has applied the technique to treatment of worry. The present study aimed first to examine the relationship between trait worry and properties of future-oriented worry images, and second to examine the efficacy of a self-guided imagery rescripting intervention in improving individuals' response to their worries.

METHODS

Participants recruited through Amazon Mechanical Turk (N = 365) identified their major worry and wrote the script of a worst-case scenario mental image. Participants were randomized to three conditions: re-writing the same worry image script (exposure), or writing scripts of either one or three positive alternative future-oriented images (rescripting conditions).

RESULTS

In preliminary analyses, trait worry negatively predicted participants' ratings of worry images, including valence and ability to cope, and positively predicted distress, anticipated cost, and belief in their negative meaning. In experimental analyses, linear mixed-effects models revealed anxious response and cognitive appraisal of the threat were significantly lower among participants allocated to rescripting relative to exposure. There was no effect of rescripting type.

CONCLUSIONS

This investigation demonstrated the impact of a future-oriented imagery rescripting task on anxiety and cognitive biases associated with real worries in an unselected sample. Results may contribute to the development of imagery rescripting interventions for GAD.

Interventions Targeting Negative Mental Imagery in Social Anxiety: A Systematic Review and Meta-Analysis of Characteristics and Outcomes

Psychological treatment for social anxiety disorder (SAD) has been found to be less effective than for other anxiety disorders. Targeting the vivid and distressing negative mental images typically experienced by individuals with social anxiety could possibly enhance treatment effectiveness. To provide both clinicians and researchers with an overview of current applications, this systematic review and meta-analysis aimed to evaluate the possibilities and effects of imagery-based interventions that explicitly target negative images in (sub)clinical social anxiety. Based on a prespecified literature search, we included 21 studies, of which 12 studies included individuals with a clinical diagnosis of SAD. Imagery interventions (k = 28 intervention groups; only in adults) generally lasted one or two sessions and mostly used imagery rescripting with negative memories. Others used eye movement desensitization and reprocessing and imagery exposure with diverse intrusive images. Noncontrolled effects on social anxiety, imagery distress and imagery vividness were mostly large or medium. Meta-analyses with studies with control groups resulted in significant medium controlled effects on social anxiety (d = -0.50, k = 10) and imagery distress (d = -0.64, k = 8) and a nonsignificant effect on imagery vividness. Significant controlled effects were most evident in individuals with clinically diagnosed versus subclinical social anxiety. Overall, findings suggest promising effects of sessions targeting negative mental images. Limitations of the included studies and the analyses need to be considered. Future research should examine the addition to current SAD treatments and determine the relevance of specific imagery interventions. Studies involving children and adolescents are warranted.

The working mechanisms of imagery rescripting and eye movement desensitization and reprocessing: Findings from a randomised controlled trial

We studied the mechanisms of eye movement desensitization and reprocessing (EMDR) and imagery rescripting (ImRs). We hypothesized that EMDR works via changes in memory vividness, that ImRs works via changes in encapsulated beliefs (EB), and that both treatments work via changes in memory distress. Patients (N = 155) with childhood-related posttraumatic stress disorder (Ch-PTSD) received 12 sessions of EMDR or ImRs. The vividness, distress, and EB related to the index trauma were measured with the Imagery Interview. PTSD severity was assessed with the Impact of Events Scale-Revised and the Clinician-Administered PTSD Scale for DSM-5. We conducted mixed regressions and Granger causality analyses. EMDR led to initially stronger changes in all predictors, but only for distress this was retained until the last assessment. No evidence for vividness as a predictive variable was found. However, changes in distress and EB predicted changes in PTSD severity during ImRs. These findings partially support the hypothesized mechanisms of ImRs, while no support was found for the hypothesized mechanisms of EMDR. Differences in the timing of addressing the index trauma during treatment and the timing of assessments could have influenced the findings. This study provides insight into the relative effectiveness and working mechanisms of these treatments.

Neural correlates of context-dependent extinction recall in social anxiety disorder: relevance of intrusions in response to aversive social experiences

BACKGROUND

There are phenomenological similarities between social anxiety disorder (SAD) and posttraumatic stress disorder, such as a provoking aversive event, posttraumatic stress symptoms (e.g. intrusions) in response to these events and deficient (context-dependent) fear conditioning processes. This study investigated the neural correlates of context-dependent extinction recall and fear renewal in SAD, specifically in patients with intrusions in response to an etiologically relevant aversive social event.

METHODS

During functional magnetic resonance imaging a two-day context-dependent fear conditioning paradigm was conducted in 54 patients with SAD and 54 healthy controls (HC). This included fear acquisition (context A) and extinction learning (context B) on one day, and extinction recall (context B) as well as fear renewal (contexts C and A) one day later. The main outcome measures were blood oxygen level-dependent responses in regions of interest and skin conductance responses.

RESULTS

Patients with SAD showed reduced differential conditioned amygdala activation during extinction recall in the safe extinction context and during fear renewal in the acquisition context compared to HC. Patients with clinically relevant intrusions moreover exhibited hypoactivation of the ventromedial prefrontal cortex (vmPFC) during extinction learning, extinction recall, and fear renewal in a novel context, while amygdala activation more strongly decreased during extinction learning and increased during fear renewal in the acquisition context compared with patients without intrusions.

CONCLUSIONS

Our study provides first evidence that intrusions in SAD are associated with similar deficits in context-dependent regulation of conditioned fear via the vmPFC as previously demonstrated in posttraumatic stress disorder.

Neurocognitive Model of Schema-Congruent and -Incongruent Learning in Clinical Disorders: Application to Social Anxiety and Beyond

Negative schemas lie at the core of many common and debilitating mental disorders. Thus, intervention scientists and clinicians have long recognized the importance of designing effective interventions that target schema change. Here, we suggest that the optimal development and administration of such interventions can benefit from a framework outlining how schema change occurs in the brain. Guided by basic neuroscientific findings, we provide a memory-based neurocognitive framework for conceptualizing how schemas emerge and change over time and how they can be modified during psychological treatment of clinical disorders. We highlight the critical roles of the hippocampus, ventromedial prefrontal cortex, amygdala, and posterior neocortex in directing schema-congruent and -incongruent learning (SCIL) in the interactive neural network that comprises the autobiographical memory system. We then use this framework, which we call the SCIL model, to derive new insights about the optimal design features of clinical interventions that aim to strengthen or weaken schema-based knowledge through the core processes of episodic mental simulation and prediction error. Finally, we examine clinical applications of the SCIL model to schema-change interventions in psychotherapy and provide cognitive-behavior therapy for social anxiety disorder as an illustrative example.

Imagery rescripting as a short intervention for symptoms associated with mental images in clinical disorders: A systematic review and meta-analysis

There is an unmet need for effective short-term therapeutic techniques to reduce clinical symptoms associated with prospective-, as well as retrospective aversive mental images across mental disorders. We investigated the efficacy of imagery rescripting (IR) as a short-term intervention across clinical disorders, as the literature suggests that this technique could be a promising intervention to reduce psychopathology by altering intrusive mental images. A systematic literature review identified 23 trials including 805 adult patients, out of which 15 trials were designed as randomized controlled trials (RCT) including patients with the following diagnoses: Social anxiety disorder (SAD), Posttraumatic-Stress-Disorder (PTSD), Bulimia Nervosa, Borderline Personality Disorder, Obsessive-Compulsive Disorder, nightmare disorder, test anxiety, health anxiety, and Generalized Anxiety Disorder. Most studies (14) comprised of one treatment session. Effect size estimates indicate that IR is highly effective in reducing clinical symptoms associated with mental images from pre-, to post-treatment (g = 1.09, 95% CI = [0.64; 1.53]), as well as from pre-treatment to follow-up (g = 1.90, 95% CI = [1.02; 2.77]). Comparing the IR intervention to a passive control group showed large effect sizes at post-treatment (g = -0.99; 95% CI = [-1.79; -0.20]), however, comparing IR to an active control group resulted in a small effect (g = -0.05; 95% CI = [-0.43; 0.33]). Lastly, large effects of IR were found for the SAD and PTSD subgroups, for comorbid symptoms of depression. In summary, our results indicate that IR is a promising short-term therapeutic technique for clinical symptoms associated with aversive prospective-, and retrospective mental images.

Efficacy of imagery rescripting in treating mental disorders associated with aversive memories - An updated meta-analysis

Imagery rescripting (ImRs) is frequently applied to treat different psychological complaints. We conducted an updated meta-analysis based on randomised controlled trials on the efficacy of ImRs for mental disorders associated with aversive memories. Medline, PsycInfo, and Web of Science were searched up to May 2023. Seventeen trials were included with a total of 908 participants (417 in the ImRs condition), suffering from posttraumatic stress disorder, anxiety disorders, depression, or eating disorders. Random effect models yielded an overall effect of g = 0.68 (95 % CI 0.18 to 1.18; k = 7) compared to passive controls (mostly waitlist). The effect compared to (prolonged) exposure, cognitive restructuring, and EMDR was non-significant (g = -0.01; 95 % CI -0.18 to 0.15; k = 11). Follow-up assessments indicated a long-term treatment effect. Results suggest that ImRs can effectively treat a variety of psychological disorders and produce similar treatment effects as evidence-based interventions. Limitations include the bounded number of included trials for each mental disorder. The meta-analysis was registered on PROSPERO (CRD42020220696) and received no funding.

Internet videoconferencing delivered cognitive behavioral therapy for social anxiety disoder: Protocol for a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) is characterized by a fear of scrutiny in social or performance situations. Due to a number of barriers, many individuals do not seek treatment for SAD, resulting in a chronic and debilitating course. Cognitive behaviour therapy (CBT), and more recently Imagery Rescripting (ImR), have been found to be efficacious in the treatment of SAD when delivered face-to-face. However, the efficacy of these treatment approaches when delivered remotely, have not yet been examined in controlled trials.

METHODS

The authors propose a two-group randomized controlled trial comparing the efficacy of videoconferencing delivered CBT (vCBT) for SAD against a waitlist control group. The study will recruit 78 adults in total with a primary diagnosis of SAD of at least moderate severity. The manualised high-intensity vCBT intervention will be delivered weekly over an 8-week period. After treatment completion, the waitlist participants will receive a high-intensity videoconferencing delivered ImR (vImR) intervention also delivered weekly over an 8-week period. Treatment for both groups will be delivered in real time via an online videoconferencing platform. Outcome measures will be administered at baseline, mid-treatment, post-treatment, and 3-month follow-up.

CONCLUSION

This trial will report findings on the efficacy of a remote synchronous high-intensity vCBT and vImR intervention for SAD and benchmark the two different treatment methodologies against standard face-to-face CBT. The results have the potential to inform best-practice remote psychological treatment for SAD.

TRIAL REGISTRATION

The trial was registered on the Australian New Zealand Clinical Trials Registry; ACTRN12623000313639 (5 April 2023).

Memory representation of aversive social experiences in Social Anxiety Disorder

Aversive social experiences are proposed to be a risk factor for developing Social Anxiety Disorder (SAD). Many patients with SAD report associated daily life symptoms, such as intrusive re-experiencing (e.g., negatively distorted images of oneself), avoidance, alterations in cognitions and mood, as well as hyperarousal, resembling symptom dimensions of Posttraumatic Stress Disorder (PTSD). These PTSD-like symptoms may result from maladaptive processing and representation of the aversive social experiences in memory. Emotional hyperreactivity during memory retrieval of aversive social experiences is another feature of SAD which was found in previous studies. This study aimed to further investigate PTSD-like symptoms and emotional reactivity associated with etiologically relevant aversive social experiences and shed more light on a potential relationship between both. Eighty-five patients with SAD and 85 healthy controls (HC) participated in this cross-sectional study. It comprised an imagination task with self-report and physiological measures to assess emotional reactivity during the cued recall of the aversive social experience and clinical interviews to assess PTSD-like symptoms. We expected increased emotional reactivity and more severe PTSD-like symptoms in response to the aversive social experience in patients with SAD compared to HC, as well as a positive correlation between emotional reactivity and PTSD-like symptoms in patients with SAD. Indeed, patients with SAD showed emotional hyperreactivity (self-report, physiology) during the cued recall of the aversive social experiences, also when compared to two control memory conditions (neutral, negative non-social) and HC. Patients with SAD furthermore reported more severe PTSD-like symptoms compared to HC and intrusive re-experiencing symptoms were positively correlated with distress during imagery of the social aversive event in patients with SAD. These results might point toward a maladaptive representation of aversive social experiences in memory. Similar to PTSD, this maladaptive memory representation might promote the development of PTSD-like symptoms such as intrusive re-experiencing (e.g., in the form of intrusive self-images in patients with SAD), which might finally lead to and maintain symptoms of SAD.

Should cognitive restructuring precede imagery rescripting? An experimental pilot study

BACKGROUND AND OBJECTIVES

Imagery rescripting (ImRs) is a promising therapeutic technique used in treatment for a variety of psychiatric disorders. During an ImRs session, an aversive disorder-related memory, is activated in imagination and rescripted to a more positive outcome. It has been shown to successfully weaken the negative cognitive meaning, so-called encapsulated beliefs of the targeted aversive memory. In many studies, ImRs is preceded by a cognitive restructuring (CR) technique focused on the encapsulated belief of the target memory. It is not clear whether adding such a CR technique is necessary or that ImRs as standalone technique can achieve comparable effects.

METHODS

Students with mild psychological distress (N = 53) were randomized over one session of cognitive restructuring plus imagery rescripting (CR + ImRs), a therapist attention placebo plus imagery rescripting (PLA + ImRs) and a double therapist attention placebo (PLA + PLA). Believability of the idiosyncratic encapsulated belief (primary outcome) and quality (vividness, distress and emotional connotation: secondary outcome) of the target memory were assessed at pre, post and at 1-week follow-up.

RESULTS

Results indicate that both, CR + ImRs and PLA + ImRs, reduced the believability of the encapsulated beliefs in greater extent than PLA + PLA. No differences appeared between the two ImRs conditions. For the secondary outcomes no differences between the three conditions were found.

LIMITATIONS

This study should be seen as a pilot study, moreover a non-clinical sample was used.

CONCLUSION

Findings suggest that a CR technique preceding ImRs is redundant. However, this study needs replication in a larger sample.

Mechanisms underlying interoceptive exposure: belief disconfirmation or extinction? A preliminary study

Interoceptive exposure, or exposure to one's feared physical sensations, has been shown to be an important technique in cognitive behavioral therapies for anxiety disorders and related constructs, such as anxiety sensitivity (AS). The current study sought to further clarify the underlying cognitive-behavioral mechanisms of interoceptive exposure in a lab-based, analog study with individuals high in AS. Participants (n = 59) were randomized into three groups: a cognitive-behavioral intervention emphasizing belief disconfirmation (CbI), a behavioral intervention emphasizing exposure (BI), and a control condition. Self-report measures assessing AS, catastrophizing of bodily sensations, and subjective units of distress (SUDS) were collected before, during and after the intervention. Participants also completed online questionnaires at a one-month follow-up. Following the CbI but not BI, a decrease was observed in both AS and catastrophizing interpretations. Furthermore, only the CbI group exhibited a decrease in SUDS ratings, whereas the BI group exhibited a significant increase. Notably, these effects were not maintained at a one-month follow-up. Findings suggest that cognitive interventions without repeated behavioral exposure may be sufficient in reducing self-reported anxiety-related symptoms and catastrophic misinterpretations, though not at maintaining them. This raises questions regarding the role of pure behavioral mechanisms in exposure.

The effect of imagery rescripting on prospective mental imagery of a feared social situation

BACKGROUND AND OBJECTIVES

Negative mental imagery appears to play a role in anxiety disorders and can involve aversive memories or anticipated future threats. Modulating aversive memories through imagery rescripting generally reduces negative memory appraisals and associated anxiety. This pre-registered two-day analog study investigated whether imagery rescripting of aversive memories also reduces negative imagery of future threats.

METHODS

On Day 1, socially anxious individuals (N = 52) were randomly assigned to imagery rescripting of an aversive memory or progressive relaxation (control condition). Before each intervention, they were asked to imagine a feared social situation that may happen in their future and evaluate this situation. They also rated the aversive memory before and after the intervention phase. The feared future situation was again evaluated at follow-up on Day 2.

RESULTS

Unexpectedly, no group differences were found on the main outcome measures. That is, negative memory appraisals reduced after both interventions. Likewise, in both groups, negative details decreased, and positive details increased in prospective mental imagery, and anxiety and avoidance towards the imagined event decreased. On the exploratory measures, the imagery rescripting group showed increased positive appraisals of memory and future threat, and decreased negative future-threat appraisals, compared to the progressive relaxation group.

LIMITATIONS

No passive control group was included, so potential time or placebo effects cannot be precluded.

CONCLUSIONS

The interventions had similar effects on the main outcomes and influenced mental imagery of future threats. Some differences were found on the exploratory measures that warrant further investigation with a passive control condition.

An Investigation of Cognitive and Affective Changes During Group Imagery Rescripting for Social Anxiety Disorder

Recurrent, negative self-imagery is common in social anxiety disorder (SAD). Imagery rescripting (ImRs) is an effective therapeutic technique that aims to target past aversive memories to modify their associated meanings, and update the encapsulated negative schematic beliefs. The current study aimed to extend previous research by investigating the cognitive and affective shifts during each phase of ImRs delivered within a group cognitive behavioral therapy protocol. Participants (N = 32) retrieved an aversive memory associated with social anxiety and were guided through brief cognitive restructuring, prior to completing ImRs. Core beliefs associated with the memory (strength and valence) and fear of negative evaluation were assessed before and after ImRs and affect was assessed following each phase. Strength and affective valence of encapsulated core beliefs about the self, others, the world, and the image itself significantly reduced following ImRs, and core beliefs were updated to become more positive. Participants reported large affective shifts early in the process, with smaller shifts in the later stages. Fear of negative evaluation did not significantly reduce following ImRs. Outcomes provide some support for cognitive and affective changes during group ImRs for SAD and suggest future research directions to investigate longer-term impacts and to better understand the underlying mechanisms of the technique.

Imagery-enhanced v. verbally-based group cognitive behavior therapy for social anxiety disorder: a randomized clinical trial

BACKGROUND

Cognitive behavior therapy (CBT) is effective for most patients with a social anxiety disorder (SAD) but a substantial proportion fails to remit. Experimental and clinical research suggests that enhancing CBT using imagery-based techniques could improve outcomes. It was hypothesized that imagery-enhanced CBT (IE-CBT) would be superior to verbally-based CBT (VB-CBT) on pre-registered outcomes.

METHODS

A randomized controlled trial of IE-CBT v. VB-CBT for social anxiety was completed in a community mental health clinic setting. Participants were randomized to IE (n = 53) or VB (n = 54) CBT, with 1-month (primary end point) and 6-month follow-up assessments. Participants completed 12, 2-hour, weekly sessions of IE-CBT or VB-CBT plus 1-month follow-up.

RESULTS

Intention to treat analyses showed very large within-treatment effect sizes on the social interaction anxiety at all time points (ds = 2.09-2.62), with no between-treatment differences on this outcome or clinician-rated severity [1-month OR = 1.45 (0.45, 4.62), p = 0.53; 6-month OR = 1.31 (0.42, 4.08), p = 0.65], SAD remission (1-month: IE = 61.04%, VB = 55.09%, p = 0.59); 6-month: IE = 58.73%, VB = 61.89%, p = 0.77), or secondary outcomes. Three adverse events were noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up).

CONCLUSIONS

Group IE-CBT and VB-CBT were safe and there were no significant differences in outcomes. Both treatments were associated with very large within-group effect sizes and the majority of patients remitted following treatment.

Potential processes of change in MDMA-Assisted therapy for social anxiety disorder: Enhanced memory reconsolidation, self-transcendence, and therapeutic relationships

OBJECTIVE

Researchers have suggested that psychotherapy may be enhanced by the addition of 3,4-methylenedioxymethamphetamine (MDMA), particularly in the treatment of disorders wherein interpersonal dysfunction is central, such as social anxiety disorder. We review literature pertaining to three potential processes of change that may be instigated during sessions involving MDMA administration in the treatment of social anxiety disorder.

DESIGN

This is a narrative review that integrates research on the etiology and maintenance of social anxiety disorder and mechanisms of action of MDMA to examine how MDMA may enhance psychotherapy outcomes.

RESULTS

We first outline how MDMA may enhance memory reconsolidation in social anxiety disorder. We then discuss how MDMA may induce experiences of self-transcendence and self-transcendent emotions such as compassion, love, and awe; and how these experiences may be therapeutic in the context of social anxiety disorder. We subsequently discuss the possibility that MDMA may enhance the strength and effectiveness of the therapeutic relationship which is a robust predictor of outcomes across many disorders as well as a potential key ingredient in treating disorders where shame and social disconnection are central factors.

CONCLUSION

We discuss how processes of change may extend beyond the MDMA dosing sessions themselves.

Recall, response bias and recognition are differentially impacted by social anxiety irrespective of feedback modality

BACKGROUND AND OBJECTIVES

This study replicates and extends Houle-Johnson et al.'s (2019) findings to better understand the role of feedback modality, ambiguity and social anxiety in the recognition and recall of self-relevant feedback.

METHODS

Participants gave a speech and were provided with positive, negative, and ambiguous feedback via written text, (n = 33) or recorded sentences (n = 31) and later completed a recognition and recall task for the feedback.

RESULTS

Recognition (p = .80, η_p² = 0) and recall (p = .09, η_p² = 0.08) did not differ between written or recorded feedback. All participants demonstrated a negative response bias (p < .001, η_p² = 0.22) and recalled more negative than positive feedback (p = .02, η_p² = 0.10) but were no more accurate in recognizing negative compared to positive feedback (p = .08, η_p² = 0). Although social anxiety did not impact recognition accuracy (p = .94, η_p² = 0), participants with high social anxiety demonstrated a more pronounced negative response bias (p < .01, η_p² = 0.11) and negative recall bias (p = .02, SE = 1.12) than low social anxiety participants. Moreover, the more negatively ambiguous items were perceived, the more likely they were identified old in the high social anxiety group, whereas the opposite was true for the low social anxiety group (B = .13, p < .10).

LIMITATIONS

Task believability was relatively low across all participants.

CONCLUSIONS

Our findings suggest that modality does not influence memory for feedback. Moreover, social anxiety might be characterized by a negative bias in recall and response bias, but not necessarily increased accuracy in recognition of negative feedback.

Imagery rescripting and negative self-imagery in social anxiety disorder: a systematic literature review

BACKGROUND

Imagery rescripting (IR) is an effective intervention for social anxiety disorder (SAD) that targets memories of distressing formative events linked to negative self-imagery (NSI). IR is thought to update unhelpful schema by addressing the needs of the younger self within the memory. An accumulating body of evidence indicates that by modifying NSI, IR can significantly affect distressing imagery, memory appraisal, and beliefs about the self.

AIMS

This systematic review aims to critically evaluate and synthesise literature investigating the existing research on the effects IR has on NSI in SAD.

METHOD

A systematic electronic search of Academic Search Complete, ProQuest, Medline, Scopus and PubMed was performed in February 2021 using pre-defined criteria. Ten studies met the inclusion criteria and were selected for review.

RESULTS

Analysis of the reviewed articles' findings identified three main themes: Changes to negative self-images, Memories linked to images and Encapsulated beliefs. IR was associated with significant decreases in image distress, image vividness, memory vividness, memory distress, and encapsulated beliefs. Although reductions were found with image frequency, they were non-significant. Interpretation of results is limited by the small number of studies.

CONCLUSIONS

IR appears to effectively alter images, memories and beliefs in SAD in as little as a single session. The findings indicate that IR could be utilised as a cost-effective intervention for SAD. However, additional studies and longer-term follow-ups are needed.

Social phobic beliefs mediate the relationship between post-event processing regarding the worst socially aversive experience and fear of negative evaluation

The experience of socially aversive events is proposed to be a critical etiological factor in the development of social anxiety symptoms even though the experience itself is also common among healthy individuals. Rather than the event itself, accompanying factors such as maladaptive processing might be associated with higher levels of social anxiety symptoms. One-hundred-seventy-four individuals participated in this online-survey comprising questionnaires regarding social anxiety symptoms and retrospective reports concerning maladaptive processing of the worst socially aversive event. Structural equation modelling was used to analyze the hypothesized mediation of maladaptive processing and fear of negative evaluation by intrusive re-experiencing and social phobic beliefs. The positive association between retrospectively evaluated maladaptive processing after the worst socially aversive event and fear of negative evaluation was mediated by social phobic beliefs but not by intrusive re-experiencing. These results point towards the relevance of further investigating processing strategies after socially aversive events as a potential influencing factor for SAD development. Trial registration. The trial was registered at the German Clinical Trial Register (DRKS00021502) on June 3rd, 2020.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12144-022-02805-9.

Group Imagery Rescripting on Childhood Memories Delivered via Telehealth: A Preliminary Study

BACKGROUND

Imagery Rescripting (ImR) has proved to be effective in the treatment of different mental disorders as an integral part of broader clinical protocols or as a standalone technique. ImR has also been successfully incorporated as part of group Schema Therapy treatment; however, to the best of our knowledge, it has never been assessed as a standalone technique in a group setting.

AIM

In this study, we focused on ImR delivered via telehealth in groups and we aimed to assess whether group ImR is effective in responding to basic emotional needs, in changing participants' affective state, and in reducing dysfunctional beliefs. We also wanted to assess whether memory realism is associated with a greater effectiveness of the technique.

METHODS

A total of 52 participants were presented with 3 ImR sessions on childhood memories related to the current dysfunctional belief that elicited more suffering.

RESULTS

The technique was effective in facilitating the retrieval of a memory in almost the entire sample (in the range of 92.3-100%). Overall, memory realism values (level of vividness, ability to immerse, and participants' distance from the images) were high in all three sessions. Almost all participants were reported having their needs met during ImR (89.7%). Importantly, need satisfaction was associated with the ability to immerse in the image. In addition, the intensity of the dysfunctional belief decreased significantly from pre-test to Session 3. The technique also changed the affective state, reducing arousal. Importantly, we also observed a general reduction in shame levels from the first to the third session.

CONCLUSION

A telehealth delivered ImR group intervention on childhood memories provides cognitive and emotional improvement. Along with the ability to satisfy the patient's basic emotional needs, the technique seems to be effective in modifying maladaptive beliefs encapsulated in memory.

Mental Imagery in Patients with Prolonged Grief Disorder: a Comparison with Matched Bereaved Healthy Controls

Mental imagery is a transdiagnostic feature that has been increasingly researched in mental disorders in the past years. This study is the first to investigate mental imagery in individuals suffering from Prolonged Grief Disorder (PGD), a new disorder which will be included into the new edition of the International Classification of Diseases and Related Health Problems (ICD-11).Our objective was to find out to what extent patients suffering from PGD differ from healthy, but equally bereaved, controls in terms of mental imagery, and how mental imagery is related to psychopathology. Patients with PGD and matched bereaved healthy controls (n = 54) completed a mental imagery questionnaire specifically designed for the study, and other established measures of psychopathology. Patients suffering from PGD reported mental images more frequently, had less control over them, and described negative images as more vivid than did healthy controls. Also, in reaction to mental images, patients less frequently experienced joy, but more often grief, anger and guilt. Besides these group differences, significant correlations between mental imagery other psychopathological measures could be found. Mental imagery is clearly related to PGD. The underlying mechanisms on whether it is a developing or maintaining factor need to be addressed in future studies. Future research should also investigate in what way mental imagery might be used in therapeutic approaches.

The effect of twice-weekly versus once-weekly sessions of either imagery rescripting or eye movement desensitization and reprocessing for adults with PTSD from childhood trauma (IREM-Freq): a study protocol for an international randomized clinical trial

Background

Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study’s aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated.

Methods

The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains.

Discussion

This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome.

Trial registration

Netherlands Trial Register NL6965, registered 25/04/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05712-9.

Imagery Rescripting Versus Cognitive Restructuring for Social Anxiety: Treatment Effects and Working Mechanisms

Background

Negative mental images in social anxiety are often linked to memories of distressing social experiences. Imagery Rescripting (ImRs) has been found to be a promising intervention to target aversive memories, but mechanisms underlying ImRs are largely unknown. The present study aimed (a) to investigate the effects of ImRs compared to cognitive restructuring (CR) on social anxiety symptoms and (b) to extend previous research by examining whether ImRs works by fostering reappraisal of negative emotional self-beliefs.

Method

Highly socially anxious individuals (N = 77) were randomly allocated to ImRs, CR, or no intervention control (NIC). A speech task was performed at baseline and at 1-week follow-up.

Results

Only CR significantly reduced social anxiety symptoms from baseline to follow-up. Decreases in negative appraisals and emotional distress in response to the speech task did not differ between conditions. Regarding working mechanisms, ImRs led to stronger increases in positive emotions than CR and NIC. Both CR and ImRs yielded short-term reductions in emotionally anchored idiosyncratic self-beliefs, but CR was superior to ImRs at follow-up.

Conclusions

The present study provides evidence for the efficacy of a single-session of CR for social anxiety symptoms. As one specific version of ImRs was applied, it is conceivable that other or optimized versions of ImRs might be more effective.

Harnessing emotional mental imagery to reduce anxiety and depression in young people: an integrative review of progress and promise

Emotional mental imagery is a powerful part of our mental landscape. Given its capacity to depict, process, and generate emotional events, mental imagery could have an important role in psychological therapies. This Series paper explores whether harnessing emotional mental imagery is meaningful to young people; ways in which interventions use emotional mental imagery; contextual and individual factors influencing intervention effectiveness; and mechanisms underpinning imagery techniques. We completed a systematic review of imagery interventions and consulted young people with lived experience (n=10) and leading international experts (n=7). The systematic search identified 86 papers covering a diverse range of imagery interventions. Across the seven categories of techniques reviewed, imagery rescripting for aversive memories, techniques targeting positive imagery, and imagery-enhanced protocols indicated the most potential. The report suggests that harnessing emotional mental imagery in psychological interventions could be a promising approach to reduce anxiety and depression and that mental health science could inform the development of new interventions and help to maximise intervention effectiveness.

Psychological and Physiological Effects of Imagery Rescripting for Aversive Autobiographical Memories

Background

Imagery Rescripting (ImRs) is a promising intervention to reduce symptoms associated with aversive memories, but little is known about its working mechanisms. The present study investigates whether ImRs increases perceived mastery and attenuates emotional reactivity to memory retrieval on a subjective and physiological level.

Methods

Seventy-nine individuals reporting memories of distressing real-life events were randomly allocated to ImRs, positive imagery (PI), or no-intervention control (NIC). The memory was reactivated before the intervention and at 1-week follow-up to assess subjective measures and physiological reactivity (heart rate [HR], skin conductance level [SCL], and facial electromyography activity [EMG]) during memory retrieval.

Results

ImRs was superior to PI and NIC on subjective memory distress and helplessness, but not on other emotions. ImRs did not exceed PI and NIC in reducing state stress symptoms or increasing perceived mastery. Physiological reactivity (HR, EMG) decreased from pre-intervention to follow-up with no differences between groups.

Conclusions

Positive effects of ImRs on helplessness and distress were found. Null findings regarding mastery might result from timing of its assessment or the fact that rather high-functioning participants were included. The lack of between group differences on physiological responses indicates that ImRs did not exceed habituation effects in the present sample.

Physiological activation and co-activation in an imagery-based treatment for test anxiety

Objective: The effectiveness of Imagery Rescripting (IR) has been demonstrated in the treatment of various psychological disorders, but the mechanisms underlying it remain unclear. While current investigations predominantly refer to memory processes, physiological processes have received less attention. The main aim of this study is to test whether client physiological activation (i.e., arousal) and client-therapist physiological activation (i.e., synchrony) during IR segments predicted improvement on next-session outcomes and overall treatment response, and to compare these to the role of physiological (co)-activation during traditional cognitive-behavioral (CB) segments. Methods: The results are based on 177 therapy sessions from an imagery-based treatment for test anxiety with 60 clients. Client and therapist electrodermal activity was continuously monitored, next-session outcome was assessed with the Outcome Rating Scale and treatment outcome was assessed using the Test Anxiety Inventory. Results: Hierarchical linear models demonstrated that average physiological synchrony during IR segments (but not during CB ones) was significantly associated with higher well-being at both the session and the overall treatment levels. Clients' physiological arousal in either IR or CB segments was not predictive of either outcome. Conclusion: These results provide initial evidence for the idea that physiological synchrony might be an important underlying mechanism in IR.

Using Imagery Rescripting as an Early Intervention for Depression in Young People

Innovation is urgently needed for school-based early interventions for depression. Imagery rescripting for aversive memories has been shown to be a valuable therapeutic approach in adults. Yet it is rarely applied to young people or to depression. This is surprising given that intrusive images of aversive memories are implicated in the development and maintenance of depression. We review the literature and describe the co-development of an imagery rescripting protocol for young people (age 16-18) with high symptoms of depression. To contextualize and illustrate this approach, we identify three themes of negative images emerging from the 37 participants who completed imagery rescripting and provide a detailed case example for each theme. The identified themes are failure, interpersonal adversity, and family conflict or disruption. Given that there is some therapist concern about using imagery rescripting, we highlight any reported negative consequences of engaging in imagery rescripting. We propose that imagery rescripting is an acceptable and potentially effective tool for early intervention in depression, which is significantly underutilized in current practice.

Online imagery rescripting among young women at risk of developing an eating disorder: A randomized controlled trial

OBJECTIVE

This study compared the effectiveness of two approaches to imagery rescripting (body versus general) among young women with an elevated risk of developing an eating disorder.

METHOD

University students (N = 130 females) were randomly assigned to one of the four conditions: body or general imagery rescripting, psychoeducation, control. After initial brief laboratory training delivered online, participants in the imagery rescripting conditions were asked to practice imagery rescripting for 5 min each day for a week. Primary (global eating psychopathology, eating disorder behaviors, and body image acceptance) and secondary outcomes (self-compassion, fear of self-compassion, and dysfunctional attitudes) were measured at baseline and one-week follow up.

RESULTS

Completer analyses showed both imagery rescripting conditions and psychoeducation had significant impact on global eating psychopathology and body acceptance (d = 0.60-0.78). Psychoeducation did not impact secondary variables, whereas body imagery rescripting improved self-compassion and fear of self-compassion (d = 0.61-0.80) and general imagery rescripting improved dysfunctional attitudes (d = 0.82) compared to control. Intent to treat analyses had similar but slightly less robust results.

DISCUSSION

While three active groups had significant impact on the primary variables, imagery rescripting approaches had impact on other variables that maintain disordered eating. Future research should investigate the impact of combining psychoeducation and imagery rescripting in terms of impact on disordered eating.

A plea for more attention to mental representations

In this invited essay I plead for a renewed attention to mental representations in research into psychopathology and its treatment. With the cognitive revolution in the second half of the previous century most psychological models of psychopathology were based on people's capacity to form mental representations of the world. However, much research effort was put into investigating cognitive biases instead of investigating mental representations, and attention shifted towards such biases, including claims that they are causal in psychopathology. Similar claims were made about emotion regulation difficulties. Moreover, in many treatment models that were developed the focus was more on cognitive biases and emotion regulation, than on underlying representations. In this essay I argue that the causal status of cognitive biases, emotion regulation, and similar phenomena is overestimated, and that in clinical reality such phenomena can be best conceptualized as output of activated mental representations. Moreover, I argue that the disappointing effectiveness and protection to relapse of many current psychological treatments are related to not addressing the underlying mental representation. Next I discuss aspects of mental representations that are important for understanding and treating psychopathology, after which I discuss the clinical implications. I sketch how better understanding the specificities of mental representations can help us to improve psychological treatments, and I make some suggestions for future research.

Imagery Rescripting for Anxiety Disorders and Obsessive-Compulsive Disorder: Recent Advances and Future Directions

PURPOSE OF REVIEW

This review describes imagery rescripting (ImRs) and its clinical application to anxiety disorders and obsessive-compulsive disorder (OCD). Variations in ImRs delivery, clinical evidence, and theories of potential mechanisms of change are also reviewed. Finally, we propose a future research agenda.

RECENT FINDINGS

There is some evidence that ImRs affects memory processes and schemas. ImRs is associated with reductions in cognitive-affective, physiological and behavioural symptoms of social anxiety disorder and reductions in OCD-related distress and OCD symptoms. ImRs for other anxiety disorders has not been evaluated. While ImRs appears to be an effective intervention for social anxiety disorder and OCD, more research is needed to (a) systematically compare ImRs to established interventions, (b) evaluate ImRs for other anxiety disorders, (c) test theorized mechanisms of change, and (d) evaluate the impact of moderating factors and treatment variations on therapeutic outcomes.

The effects of imagery rescripting on memory outcomes in social anxiety disorder

Imagery rescripting (IR) is an effective intervention for social anxiety disorder (SAD) that targets negative autobiographical memories. IR has been theorized to work through various memory mechanisms, including modifying the content of negative memory representations, changing memory appraisals, and improving negative schema or core beliefs about self and others. However, no prior studies have investigated the unique effects of rescripting itself relative to other IR intervention components on these proposed mechanisms. In this preliminary study, 33 individuals with SAD were randomized to receive a single session of IR, imaginal exposure (IE), or supportive counselling (SC). Memory outcomes were assessed at 1- and 2-weeks post-intervention and at 3-months follow-up. Results demonstrated that the content of participants' autobiographical memory representations changed in distinct ways across the three conditions. Whereas IR facilitated increases only in positive/neutral memory details, IE facilitated increases in both positive/neutral and negative memory details and SC facilitated no changes in memory details. Although memory appraisals did not differ across conditions, participants who received IR were more likely to update their negative memory-derived core beliefs. These unique effects of rescripting on memory representations and core beliefs enhance our understanding of the memory-based mechanisms of IR within the context of exposure-based learning for people with SAD.

Imagery Rescripting and Exposure in Social Anxiety: A Randomized Trial Comparing Treatment Techniques

This randomized trial compared the effects of imagery rescripting against in vivo exposure administered separately during a single session with 27 socially anxious individuals. Previous research shows that imagery rescripting is a promising treatment technique for various disorders including social anxiety, although imagery rescripting and exposure for social anxiety have not yet been compared. Social anxiety self-report measures (LSAS-SR and BFNE-II); the distress, vividness, and frequency of fear images (i.e., Imagery condition); and the levels of anxiety, avoidance, and the strength of convictions of a feared social situation (i.e., exposure condition) were rated at baseline, before treatment, and after a 2- and 4-week follow up period. Both treatment groups improved significantly on all measures pre- to post treatment and the effects largely remained at the 4-week follow-up. No significant differences between the treatment groups were found on the anxiety measures. The results suggest that either a single session of imagery rescripting or of exposure are effective in reducing social anxiety, and that both treatment techniques, even when administered in a single session, reduces social anxiety.

Patients’ perspectives on imagery rescripting for aversive memories in social anxiety disorder

Background:

Imagery rescripting (IR) for early aversive memories in patients with social anxiety disorder (SAD) has shown promising results, but no study has investigated the reactions and perspectives of patients who received IR.

Aims:

This study aimed to gain understanding of patients’ experiences/perspectives on IR as an adjunct to cognitive behavioural therapy (CBT) for SAD.

Method:

Twenty-five individuals with SAD received one or two sessions of IR over 16 CBT sessions. Contents of recurrent images and linked memories were identified during IR. Outcome measures included social anxiety, image and memory distress and vividness, and encapsulated belief. Patients completed a questionnaire about their perspectives of IR after the session. Thematic analysis was used to analyse the qualitative data.

Results:

IR resulted in significant within-session improvement in most outcome measures. Linked memories to negative recurrent images in social situations were categorized into nine groups. Common memories were ‘Being criticized by others’, ‘Being made fun of’, ‘Failing or not doing something well’ and ‘Being left out in a group’. Most patients (82%) experienced IR as impressive, and more than half of patients (59%) found IR effective. Themes of reasons of impressiveness and effectiveness were categorized as ‘Results of IR session’ and ‘Processes of IR session’. The theme ‘Results of IR session’ included six subthemes, and the theme ‘Processes of the IR session’ included five subthemes.

Conclusions:

Regarding patients’ perspectives, although they may experience negative emotions in the process of an IR session, our results suggest that many patients with SAD found IR sessions effective.

“Being Unfilial Condemns You to Hell”: Integrative Treatment for Social Anxiety Shaped by Domestic Abuse, Confucian Values, and Taoist Beliefs

Social anxiety is a common and treatable condition but less is known about how to adapt evidence-based approaches in a culture-sensitive way to Asian clients. We present the case of “Sally,” a 25-year-old Chinese Singaporean female who suffered from severe and long-standing social anxiety disorder (SAD), and secondary low mood. Contributing factors included a history of domestic abuse, as well as culturally influenced authoritarian parenting emphasizing the Confucian value of filial piety and reinforced by Taoist beliefs of karmic retribution and supernatural punishment. Treatment was based on Clark and Wells’s cognitive model of SAD with a focus on behavioral experiments, and was enhanced using a schema mode formulation and imagery rescripting to address relevant early memories that were at the origin of the social anxiety. Sally received a total of 42 sessions over the course of 21 weeks, during which she made steady progress toward recovery. Her self-reported depression and social phobia fell from the “severe clinical” range pretreatment to the “non-clinical” range posttreatment; these gains were maintained at 6 months follow-up. Sally’s functioning fully recovered, and she returned to work and school. While behavioral experiments for dropping safety behaviors were useful for overcoming the social anxiety, schema formulation was important for providing Sally with insight to her thought process, and imagery rescripting was crucial for weakening her self-criticism and internalized black and white thinking on filial piety. The significance of culture and religion in SAD, and the potential of adapting cognitive therapy in a culture-sensitive way is discussed.

Imagery rescripting of traumatic memories for panic disorder: an exploratory study

Imagery rescripting (ImRs) is a psychological intervention designed to change the meaning of images and associated memories and reduce emotional distress. Recent studies have shown that ImRs can be successfully applied to many psychological problems and disorders; however, little has been reported on the application of ImRs for panic disorder (PD). Consequently, we explored the therapeutic effects of ImRs on patients with PD. Fifteen patients with PD received 16 individual cognitive behavioural therapy (CBT) sessions weekly, including one ImRs session. Early traumatic memories associated with recurrent images in panic situations were identified and rescripted to alleviate maladaptive encapsulated beliefs. ImRs ratings (vividness and distress of the images and memories and conviction degree of encapsulated beliefs) were measured prior to and after ImRs. Self-negative contents not directly related to symptoms of panic attack were observed as common themes in the worst meaning of the image, the memory, and in the encapsulated belief. Whilst five (33%) patients had anticipatory anxiety, 10 (67%) patients had other self-negative beliefs. ImRs significantly reduced distress from images, memories and encapsulated beliefs; however, it did not change the vividness of images and memories. There was no significant correlation between the reduction in PD severity over the CBT program and the change in each ImRs rating. The results of this study are promising for certain aspects of panic disorder. However, further research is needed to overcome the limitations of this study.

Changes in perceived centrality of anxious events following cognitive behavioral therapy for social anxiety disorder and panic disorder

BACKGROUND AND OBJECTIVE

The purpose of the present study was to explore the association between reductions in symptoms of psychopathology and perceived centrality of negative autobiographical memories in participants with social anxiety disorder (SAD) or panic disorder (PD).

METHODS

Thirty-nine individuals with SAD or PD recalled and rated four negative autobiographical memories before and after ten sessions of cognitive behavioral therapy (CBT) over a three-month period. Twenty-eight healthy controls did the same before and after a three-month period.

RESULTS

As hypothesized, results showed a decrease in perceived centrality following CBT. This decrease in perceived centrality was larger, although at the trend level, for individuals who experienced reliable change on disorder-specific symptoms.

LIMITATIONS

The correlational nature of the study prevents establishing the causal relationship between changes in perceived centrality and psychopathology, and future studies should explore such mechanisms.

CONCLUSIONS

The present study adds to the emerging body of literature, investigating changes in centrality of event following psychotherapy.

Rescripting Memory, Redefining the Self: A Meta-Emotional Perspective on the Hypothesized Mechanism(s) of Imagery Rescripting

Imagery Rescripting (ImRs) is a therapeutic technique that aims to reduce the distress associated with negative memories of early aversive experiences. It consists of prompting patients to rescript the autobiographical memory in line with their unmet needs. In recent years, ImRs was found effective in reducing symptoms of disorders such as depression, social phobia, obsessive-compulsive disorder, post-traumatic stress disorder, and personality disorders. However, the cognitive mechanisms underlying such broad effectiveness are currently an object of debate. Empirical evidence has shown that ImRs reduces the negative self-belief derived from aversive memories in different types of mental disorders. However, existing accounts are not very accurate in explaining how this change in self-belief occurs and therefore why ImRs is effective across psychopathologies. We propose that ImRs changes the semantic self-representation encapsulated in the aversive memory by reducing the meta-emotional problem (i.e., perceiving a negative emotion as problematic and unacceptable). Empirical evidence implicates the meta-emotional problem or “secondary problem” in the maintenance of different disorders and has shown that treating it leads to symptoms reduction. Here we hypothesize that: (i) ImRs as a stand-alone treatment may lead to a reduction of symptoms; negative self-belief and the meta-emotional problem; and (ii) the reduction of the meta-emotional problem might mediate the relation between symptoms and negative self-belief reduction. To test our hypothesis, we present an experimental procedure that could be used in future studies. We conclude discussing the existing theoretical frameworks that attempt to unravel the mechanisms that play a role in ImRs.

Association between Social Anxiety and Visual Mental Imagery of Neutral Scenes: The Moderating Role of Effortful Control

According to cognitive theories, verbal processing attenuates emotional processing, whereas visual imagery enhances emotional processing and contributes to the maintenance of social anxiety. Individuals with social anxiety report negative mental images in social situations. However, the general ability of visual mental imagery of neutral scenes in individuals with social anxiety is still unclear. The present study investigated the general ability of non-emotional mental imagery (vividness, preferences for imagery vs. verbal processing, and object or spatial imagery) and the moderating role of effortful control in attenuating social anxiety. The participants (N = 231) completed five questionnaires. The results showed that social anxiety was not necessarily associated with all aspects of mental imagery. As suggested by theories, social anxiety was not associated with a preference for verbal processing. However, social anxiety was positively correlated with the visual imagery scale, especially the object imagery scale, which concerns the ability to construct pictorial images of individual objects. Further, it was negatively correlated with the spatial imagery scale, which concerns the ability to process information about spatial relations between objects. Although object imagery and spatial imagery positively and negatively predicted the degree of social anxiety, respectively, these effects were attenuated when socially anxious individuals had high effortful control. Specifically, in individuals with high effortful control, both object and spatial imagery were not associated with social anxiety. Socially anxious individuals might prefer to construct pictorial images of individual objects in natural scenes through object imagery. However, even in individuals who exhibit these features of mental imagery, effortful control could inhibit the increase in social anxiety.