Picturing self-harm: Investigating flash-forward mental imagery as a proximal and modifiable driver of non-suicidal self-injury.

OBJECTIVES: Non-suicidal self-injury (NSSI) is theorized to be reinforced by its emotional consequences. Mental images of NSSI are commonly reported as occurring prior to NSSI. Based on the known functional properties of anticipatory mental imagery as an emotional and motivational amplifier, this study investigated whether NSSI mental imagery constitutes a proximal and dynamic mechanism underpinning NSSI risk. METHOD: An intensive ecological momentary assessment (EMA) study was conducted to track the occurrence and characteristics of NSSI mental imagery alongside NSSI urge and behavior in naturalistic settings. A sample of N = 43 individuals aged 17 to 24 with a history of repetitive NSSI completed EMA surveys seven times a day for 14 days. RESULTS: Mental preoccupation in the form of NSSI mental imagery-based flash-forwards to the actions, bodily sensations, and emotional benefits of NSSI was found to occur when NSSI urge was high but not when urge was low. Critically, objective cross-panel analyses showed that higher frequencies of NSSI imagery occurrence predicted greater future NSSI urge and increased likelihood of acting on urge, over and above current urge. CONCLUSIONS: Mental imagery of NSSI is not simply an epiphenomenal by-product of NSSI urge and may constitute a dynamic and proximal novel intervention target.

Mental imagery of suicide and non-suicidal self-injury: A meta-analysis and systematic review.

BACKGROUND: The vast majority of research on, and clinical assessment of, cognitions related to suicide and non-suicidal self-injury (NSSI) has focused on verbal thoughts. And yet, mental imagery is more realistic and emotionally arousing than verbal thoughts. METHODS: We conducted a systematic review and meta-analysis documenting the prevalence of suicidal and NSSI mental imagery and describing the content and characteristics of suicidal and NSSI mental imagery, links between suicidal and NSSI mental imagery and suicidal and NSSI behavior, and how to intervene on suicidal and NSSI mental imagery. Studies published through December 17, 2022 were identified through a systematic search of MEDLINE and PsycINFO. RESULTS: Twenty-three articles were included. Prevalence rates of suicidal (73.56%) and NSSI (84.33%) mental imagery were high among clinical samples. Self-harm mental imagery commonly depicts engagement in self-harm behavior and is experienced as vivid, realistic, and preoccupying. When experimentally induced, self-harm mental imagery reduces physiological and affective arousal. Preliminary evidence suggests that suicidal mental imagery is associated with suicidal behavior. CONCLUSIONS: Suicidal and NSSI mental imagery are highly prevalent and may be associated with heightened risk for self-harm behavior. Assessments and interventions for self-harm should consider incorporating and addressing suicidal and NSSI mental imagery to mitigate risk.

Telephone-Based Behavioral Activation with Mental Imagery for Depression in Older Adults in Isolation During the covid-19 Pandemic: Long-term Results from a Pilot Trial.

OBJECTIVES: The covid-19 pandemic has highlighted the need for psychological interventions for depression that can be delivered remotely to older adults. Pellas et al. (2022) conducted a pilot trial on the preliminary effectiveness of a four-week telephone-delivered Behavioral Activation with Mental Imagery (BA-MI) intervention to N= 38 adults 65 years and older with clinically significant depressive symptoms living in isolation due to covid-19 in Sweden. This study assessed the feasibility of follow-up assessments and within-group symptom change over a six-month post-intervention period. METHODS: Retention rates at post-intervention and follow-up assessments of depressive symptoms (MADRS-S) at five time points were assessed (baseline, post-intervention, 1-, 3-, and 6-month follow-up). Effect sizes (Hedges' g) for within-group change scores were calculated between each time point. RESULTS: Retention rates over time were 95, 82, 89, and 84%. Mean MADRS-S score was 18.26 at baseline, 13.69 at post-intervention (g= .68), 13.42 at 1 month (g= .74), 13.82 at 3 months (g= .74), and 15.59 at 6 months (g= .41). CONCLUSIONS: Long-term follow-ups were feasible. Within-group decreases in depressive symptoms were maintained with medium effect sizes at 6 months post-intervention. CLINICAL IMPLICATIONS: Telephone-based BA-MI may be a feasible intervention for depressive symptoms in older adults in isolation with maintained effects over time.

Telephone-based behavioral activation with mental imagery for depression: A pilot randomized clinical trial in isolated older adults during the Covid-19 pandemic.

OBJECTIVES: To shield vulnerable persons, particularly the elderly, during the Covid-19 pandemic governments around the world have advised to use social distancing and self-isolation. Social isolation might put older adults at an increased risk for mental health problems such as depression. There is a need for brief, easy-accessible psychological treatments for depressive symptoms that can be delivered remotely. The aim of this study was to investigate the feasibility, acceptability, and preliminary efficacy of telephone-delivered Behavioral Activation with Mental Imagery (BA-MI) for the treatment of depressive symptoms in individuals 65 years and older living in isolation during the Covid-19 pandemic. METHODS: In this open-label pilot randomized clinical trial, N = 41 individuals aged 65 years or older with clinically significant symptoms of depression were randomly assigned to either a BA-MI treatment condition, or an Attention-Assessment control condition delivered over the telephone over a 4-week period. RESULTS: Depressive symptoms decreased more in the treatment condition compared to the control condition. At post-treatment, 2 out of 16 participants in the treatment condition met diagnostic criteria for depression compared to 9 out of 13 in the control condition. Most participants in the treatment condition were satisfied with the treatment and few adverse effects were observed. CONCLUSIONS: This pilot study suggests that behavioral activation with mental imagery delivered over the telephone is feasible, acceptable, and potentially efficacious for the treatment of depressive symptoms in older individuals living in isolation. Replication in larger samples is needed.

Emotional mental imagery generation during spontaneous future thinking: relationship with optimism and negative mood.

Optimism is known to buffer against negative mood. Thus, understanding the factors that contribute to individual variation in optimism may inform interventions for mood disorders. Preliminary evidence suggests that the generation of mental imagery-based representations of positive relative to negative future scenarios is related to optimism. This study investigated the hypothesis that an elevated tendency to generate positive relative to negative mental imagery during spontaneous future thinking would be associated with reduced negative mood via its relationship to higher optimism. Participants (N = 44) with varied levels of naturally occurring negative mood reported current levels of optimism and the real-time occurrence and characteristics of spontaneous thoughts during a sustained attention computer task. Consistent with hypotheses, higher optimism statistically mediated the relationship between a higher proportional frequency of positive relative to negative mental imagery during spontaneous future thinking and lower negative mood. Further, the relationship between emotional mental imagery and optimism was found for future, but not past, thinking, nor for verbal future or past thinking. Thus, a greater tendency to generate positive rather than negative imagery-based mental representations when spontaneously thinking about the future may influence how optimistic one feels, which in turn may influence one's experience of negative mood.

Mental imagery-based episodic simulation amplifies motivation and behavioural engagement in planned reward activities.

Preliminary evidence suggests mental imagery-based episodic simulation of planned reward activities may amplify motivation and promote greater behavioural engagement, particularly for activities with high motivational barriers (Renner, Murphy, Ji, Manly, & Holmes, 2019). This study conducted a conceptual replication and extension of Renner et al. (2019). N = 81 first-year university students self-selected and scheduled two reward activities (one hedonic, one mastery) for the following week before being randomly allocated to either an Imagery-Experiential elaboration condition (n = 27), a Verbal-Reasoning elaboration condition (n = 28), or a Scheduling-only Control condition (n = 26). Following the lab session, all participants received standardized daily prompts to complete daily activity diaries online for seven days. The Imagery-Experiential condition reported greater increases in anticipatory pleasure (state mood), anticipated pleasure, and self-reported motivation compared to the Scheduling-only Control condition, and greater increases in anticipatory pleasure (state mood), but not anticipated pleasure or motivation, relative to the Verbal-Reasoning condition. Consistent with Renner et al. (2019), the Imagery-Experiential condition, but not the Verbal-Reasoning condition, reported more frequent engagement in high motivational barrier activities than the Scheduling-only Control condition. Exploratory mediational analyses suggested that mental imagery may exert unique motivational impacts via its impact on anticipatory pleasure (state mood), although indirect effects were only observed for self-reported motivation change in the lab, with real world behavioural effects falling short of statistical significance.

Developing thinking around mental health science: the example of intrusive, emotional mental imagery after psychological trauma.

INTRODUCTION: One route to advancing psychological treatments is to harness mental health science, a multidisciplinary approach including individuals with lived experience and end users (e.g., Holmes, E. A., Craske, M. G., & Graybiel, A. M. (2014). Psychological treatments: A call for mental-health science. Nature, 511(7509), 287-289. doi:10.1038/511287a). While early days, we here illustrate a line of research explored by our group-intrusive imagery-based memories after trauma. METHOD/RESULTS: We illustrate three possible approaches through which mental health science may stimulate thinking around psychological treatment innovation. First, focusing on single/specific target symptoms rather than full, multifaceted psychiatric diagnoses (e.g., intrusive trauma memories rather than all of posttraumatic stress disorder). Second, investigating mechanisms that can be modified in treatment (treatment mechanisms), rather than those which cannot (e.g., processes only linked to aetiology). Finally, exploring novel ways of delivering psychological treatment (peer-/self-administration), given the prevalence of mental health problems globally, and the corresponding need for effective interventions that can be delivered at scale and remotely for example at times of crisis (e.g., current COVID-19 pandemic). CONCLUSIONS: These three approaches suggest options for potential innovative avenues through which mental health science may be harnessed to recouple basic and applied research and transform treatment development.

Mental imagery as a "motivational amplifier" to promote activities.

Facilitating engagement in rewarding activities is a key treatment target in depression. Mental imagery can increase engagement in planned behaviours, potentially due to its special role in representing emotionally salient experiences. The present study tested the hypothesis that mental imagery promotes motivation and engagement when planning pleasant and rewarding activities. Participants were recruited from a community volunteer panel (N = 72). They self-nominated six activities to complete over the following week, and were randomized to either: a) a single-session Motivational Imagery condition (N = 24); b) an Activity Reminder control condition (N = 24); or c) a No-Reminder control condition (N = 24). As predicted, relative to control groups, the Motivational Imagery group reported higher levels of motivation, anticipated pleasure, and anticipated reward for the planned activities. The Motivational Imagery group also completed significantly more activities than the Activity Reminder group, but not more than the No-Reminder group. Relevance of results to behavioural activation approaches for depression are discussed.

Mental imagery in psychiatry: conceptual & clinical implications.

Mental imagery refers to the experience of perception in the absence of external sensory input. Deficits in the ability to generate mental imagery or to distinguish it from actual sensory perception are linked to neurocognitive conditions such as dementia and schizophrenia, respectively. However, the importance of mental imagery to psychiatry extends beyond neurocognitive impairment. Mental imagery has a stronger link to emotion than verbal-linguistic cognition, serving to maintain and amplify emotional states, with downstream impacts on motivation and behavior. As a result, anomalies in the occurrence of emotion-laden mental imagery has transdiagnostic significance for emotion, motivation, and behavioral dysfunction across mental disorders. This review aims to demonstrate the conceptual and clinical significance of mental imagery in psychiatry through examples of mood and anxiety disorders, self-harm and suicidality, and addiction. We contend that focusing on mental imagery assessment in research and clinical practice can increase our understanding of the cognitive basis of psychopathology in mental disorders, with the potential to drive the development of algorithms to aid treatment decision-making and inform transdiagnostic treatment innovation.

Spontaneous cognition in dysphoria: reduced positive bias in imagining the future.

Anomalies in future-oriented cognition are implicated in the maintenance of emotional disturbance within cognitive models of depression. Thinking about the future can involve mental imagery or verbal-linguistic mental representations. Research suggests that future thinking involving imagery representations may disproportionately impact on-going emotional experience in daily life relative to future thinking not involving imagery (verbal-linguistic representation only). However, while higher depression symptoms (dysphoria) are associated with impaired ability to deliberately generate positive relatively to negative imagery representations of the future (when instructed to do so), it is unclear whether dysphoria is associated with impairments in the tendency to do so spontaneously (when not instructed to deliberately generate task unrelated cognition of any kind). The present study investigated dysphoria-linked individual differences in the tendency to experience spontaneous future-oriented cognition as a function of emotional valence and representational format. Individuals varying in dysphoria level reported the occurrence of task unrelated thoughts (TUTs) in real time while completing a sustained attention go/no-go task, during exposure to auditory cues. Results indicate higher levels of dysphoria were associated with lower levels of positive bias in the number of imagery-based future TUTs reported, reflecting higher negative imagery-based future TUT generation (medium to large effect size), and lower positive imagery-based TUT generation (small to medium effect size). Further, this dysphoria-linked bias appeared to be specific in temporal orientation (future, not past) and representational format (imagery, not non-imagery). Reduced tendency to engage in positive relative to negative imagery-based future thinking appears to be implicated in dysphoria.

Effects of Engaging in Repeated Mental Imagery of Future Positive Events on Behavioural Activation in Individuals with Major Depressive Disorder.

Depression is associated with decreased engagement in behavioural activities. A wide range of activities can be promoted by simulating them via mental imagery. Mental imagery of positive events could thus provide a route to increasing adaptive behaviour in depression. The current study tested whether repeated engagement in positive mental imagery led to increases in behavioural activation in participants with depression, using data from a randomized controlled trial (Blackwell et al. in Clin Psychol Sci 3(1):91-111, 2015. doi:10.1177/2167702614560746). Participants (N = 150) were randomized to a 4-week positive imagery intervention or an active non-imagery control condition, completed via the internet. Behavioural activation was assessed five times up to 6 months follow-up using the Behavioural Activation for Depression Scale (BADS). While BADS scores increased over time in both groups, there was an initial greater increase in the imagery condition. Investigating mental imagery simulation of positive activities as a means to promote behavioural activation in depression could provide a fruitful line of enquiry for future research.

Seeing light at the end of the tunnel: Positive prospective mental imagery and optimism in depression.

Optimism is associated with positive outcomes across many health domains, from cardiovascular disease to depression. However, we know little about cognitive processes underlying optimism in psychopathology. The present study tested whether the ability to vividly imagine positive events in one's future was associated with dispositional optimism in a sample of depressed adults. Cross-sectional and longitudinal analyses were conducted, using baseline (all participants, N=150) and follow-up data (participants in the control condition only, N=63) from a clinical trial (Blackwell et al., 2015). Vividness of positive prospective imagery, assessed on a laboratory-administered task at baseline, was significantly associated with both current optimism levels at baseline and future (seven months later) optimism levels, including when controlling for potential confounds. Even when depressed, those individuals able to envision a brighter future were more optimistic, and regained optimism more quickly over time, than those less able to do so at baseline. Strategies to increase the vividness of positive prospective imagery may aid development of mental health interventions to boost optimism.

Emotional Mental Imagery as Simulation of Reality: Fear and Beyond-A Tribute to Peter Lang.

This article pays tribute to the seminal paper by Peter J. Lang (1977; this journal), "Imagery in Therapy: Information Processing Analysis of Fear." We review research and clinical practice developments in the past five decades with reference to key insights from Lang's theory and experimental work on emotional mental imagery. First, we summarize and recontextualize Lang's bio-informational theory of emotional mental imagery (1977, 1979) within contemporary theoretical developments on the function of mental imagery. Second, Lang's proposal that mental imagery can evoke emotional responses is evaluated by reviewing empirical evidence that mental imagery has a powerful impact on negative as well as positive emotions at neurophysiological and subjective levels. Third, we review contemporary cognitive and behavioral therapeutic practices that use mental imagery, and consider points of extension and departure from Lang's original investigation of mental imagery in fear-extinction behavior change. Fourth, Lang's experimental work on emotional imagery is revisited in light of contemporary research on emotional psychopathology-linked individual differences in mental imagery. Finally, key insights from Lang's experiments on training emotional response during imagery are discussed in relation to how specific techniques may be harnessed to enhance adaptive emotional mental imagery training in future research.