Developing an interpretation bias modification training task for alleviating loneliness in young people.

OBJECTIVE: Loneliness is common among young people and is associated with negative health outcomes. Because loneliness is associated with a bias for interpreting social situations as threatening, cognitive bias modification for interpretation (CBM-I) training is a potential early intervention tool. We developed and delivered a single session of mental imagery enhanced digital CBM-I training, assessing feasibility, acceptability, and magnitude of change in interpretational style and loneliness. METHOD: CBM-I training materials were developed using a co-creation approach with 18-25-year-olds with experience of loneliness. Another group of 18-25-year-olds with high loneliness received either online CBM-I (n = 29) or control (n = 27) training. RESULTS: CBM-I training uptake and retention rates were 88% and 92%, respectively. Participants found the training acceptable. The CBM-I group showed a reduction in social threat interpretations (d = 0.77), an increase in social benign interpretations (d = 0.84), and a decrease in loneliness (d = 0.56). The control group showed a small reduction in social threat interpretations (d = 0.21), no change in social benign interpretations (d = 0.04), and an increase in loneliness (d = 0.41). CONCLUSIONS: Interpretation biases relevant to youth loneliness may be modifiable, and CBM-I training could reduce feelings of loneliness. This informs psychological models of loneliness, and the development of CBM-I interventions targeting loneliness in young people.

An early intervention for adolescent depression targeting emotional mental images and memory specificity: a process evaluation.

We have evaluated a novel early intervention for adolescent depression (age 16-18) in a feasibility randomised controlled trial. This nested process evaluation aimed to understand how this complex intervention worked. We sought to understand participants' views and experiences of receiving and interacting with the intervention to evaluate whether the underpinning theoretical basis of the intervention is justified and whether it contributes to valued outcomes for participants. Twelve participants were invited to take part in semi-structured interviews. Framework analysis was employed to identify important aspects of adolescents' experiences. The active ingredients identified by participants were consistent with and extended our understanding of the theoretical basis of the intervention. Four principle themes were identified: understanding how memory works and being able to remember memories in more detail; processing negative experiences and letting go; imagining positive future events; and understanding and being kinder to myself. The outcomes of the intervention were valued by participants. Six principle themes were identified: improving mood and well-being; reducing impact of negative memories; motivation and goal-directed behaviour; overcoming avoidance and rumination; relationships, communication and being open; and self-understanding and acceptance. A simplified logic model is also proposed to connect the intervention components, active ingredients, and valued outcomes. The findings provide an in-depth understanding of how participants interacted with the intervention and what they derived from it. For example, the findings establish processing negative experiences as a core intervention component, extend it to include letting go of these memories, and highlight that reducing the impact of negative memories is valued by participants. This richer understanding guides further intervention development and future implementation.

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.

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.

Targeting image-based autobiographical memory in childhood to prevent emotional disorders: Intervention development and a feasibility randomised controlled trial.

Maladaptive cognitive styles confer vulnerability for emotional disorders and may emerge in childhood. In three phases, we developed and evaluated a novel parent-led intervention (My Memory Forest) to target overgeneral memory and avoidance of negative memories. In phase 1, the intervention was co-designed using two focus groups (n = 30 children) and consultation with teachers and parents. The acceptability, feasibility, and clinical potential of My Memory Forest was initially evaluated in phase two (n = 12 children aged 6 to 9) and then in a feasibility randomised controlled trial in phase three, against an active control (n = 56 aged 6 to 9). Acceptability and engagement were good, and no harm was reported by parents or participants. Phase 2 identified decreases in self-reported anxiety (d = 1.08), depression (d = 0.51) and vividness of negative events (d = 0.53). There was little change in parent-reported symptoms. In phase 3, recruitment was highly feasible and participant retention excellent (100%) but parent retention poor (55%). Descriptive statistics indicated similar changes in anxiety and depression for both groups. Changes between Phases 2 and 3 (e.g. methods of recruitment) could explain the discrepancy between results. Further development is necessary before proceeding to another trial. TRIAL REGISTRATION: ISRCTN13142918.

A feasibility randomised controlled trial of a brief early intervention for adolescent depression that targets emotional mental images and memory specificity (IMAGINE).

Brief, evidence-based interventions for adolescent depression are urgently required, particularly for school-settings. Cognitive mechanisms research suggests dysfunctional mental imagery and overgeneral memory could be promising targets to improve mood. This feasibility randomised controlled trial with parallel symptomatic groups (n = 56) compared a novel imagery-based cognitive behavioural intervention (ICBI) to non-directive supportive therapy (NDST) in school settings. Blind assessments (of clinical symptoms and cognitive mechanisms) took place pre-intervention, post-intervention and follow-up three months later. The trial aimed to evaluate the feasibility and acceptability of the methodology and interventions, and estimate the likely range of effects of the intervention on self-reported depression. The pre-defined criteria for proceeding to a definitive RCT were met: full recruitment occurred within eleven months; retention was 89%; ICBI acceptability was above satisfactory; and no harm was indicated. Intention-to-treat analysis found large effects in favour of ICBI (relative to NDST) at post-intervention in reducing depressive symptoms (d = -1.34, 95% CI [-1.87, -0.80]) and improving memory specificity (d = 0.79 [0.35, 1.23]), a key cognitive target. The findings suggest that ICBI may not only improve mood but also strengthen abilities associated with imagining and planning the future, critical skills at this life stage. A fully powered evaluation of ICBI is warranted. Trial Registration: https://www.isrctn.com/; ISRCTN85369879.

Intrusive images of a distressing future: Links between prospective mental imagery, generalized anxiety and a tendency to suppress emotional experience in youth.

Distressing intrusive images commonly occur in anxiety. Worry may function to reduce the emotional power of intrusive imagery, but this also prevents emotional processing. As worry is a future-orientated process, suppression of intrusive future imagery could be particularly pertinent to generalized anxiety. Here, we investigate whether youth high in symptoms of generalized anxiety (compared to depression and social anxiety) experience greater impact of future imagery (more intrusions, hyperarousal and avoidance), and whether this relationship varies as a function of the tendency to suppress or reappraise emotional experience. These relationships are important in adolescence, when generalized anxiety commonly begins and emotional regulation strategies develop. Participants (n = 352, age 11-16) completed measures of symptomatology, the impact of prospective personally-relevant imagery (IFES) and emotional regulation strategies. IFES scores correlated with an established measure of prospective imagery. Higher IFES scores were uniquely associated with more symptoms of generalized anxiety and depression, but not with social anxiety. A tendency to supress emotion was related to higher IFES scores and moderated the relationship between generalized anxiety and IFES (but not between depression and IFES). This provides initial impetus to develop novel approaches to investigate and intervene cognitively with negative prospective imagery in adolescent generalized anxiety.

A brief early intervention for adolescent depression that targets emotional mental images and memories: protocol for a feasibility randomised controlled trial (IMAGINE trial).

BACKGROUND: Adolescent depression is common and impairing. There is an urgent need to develop early interventions to prevent depression becoming entrenched. However, current psychological interventions are difficult to access and show limited evidence of effectiveness. Schools offer a promising setting to enhance access to interventions, including reducing common barriers such as time away from education. Distressing negative mental images and a deficit in positive future images, alongside overgeneral autobiographical memories, have been implicated in depression across the lifespan, and interventions targeting them in adults have shown promise. Here, we combine techniques targeting these cognitive processes into a novel, brief psychological intervention for adolescent depression. This feasibility randomised controlled trial will test the feasibility and acceptability of delivering this imagery-based cognitive behavioural intervention in schools. METHODS/DESIGN: Fifty-six adolescents (aged 16-18) with high symptoms of depression will be recruited from schools. Participants will be randomly allocated to the imagery-based cognitive behavioural intervention (ICBI) or the control intervention, non-directive supportive therapy (NDST). Data on feasibility and acceptability will be recorded throughout, including data on recruitment, retention and adherence rates as well as adverse events. In addition, symptom assessment will take place pre-intervention, post-intervention and at 3-month follow-up. Primarily, the trial aims to establish whether it is feasible and acceptable to carry out this project in a school setting. Secondary objectives include collecting data on clinical measures, including depression and anxiety, and measures of the mechanisms proposed to be targeted by the intervention. The acceptability of using technology in assessment and treatment will also be evaluated. DISCUSSION: Feasibility, acceptability and symptom data for this brief intervention will inform whether an efficacy randomised controlled trial is warranted and aid planning of this trial. If this intervention is shown in a subsequent definitive trial to be safe, clinically effective and cost-effective, it has potential to be rolled out as an intervention and so would significantly extend the range of therapies available for adolescent depression. This psychological intervention draws on cognitive mechanism research suggesting a powerful relationship between emotion and memory and uses imagery as a cognitive target in an attempt to improve interventions for adolescent depression. TRIAL REGISTRATION: ISRCTN85369879.

Looking forward to the future: Impoverished vividness for positive prospective events characterises low mood in adolescence.

BACKGROUND: Enhancing positive future imagery offers promise for treatment innovation in adult depression but has been neglected in adolescence. While negative life events are linked with depression-onset in adolescence, mechanisms underlying this association are poorly understood. We investigate whether difficulties in generating vivid positive future imagery characterise depression, compared to anxiety, and examine potential moderation of the relationship between negative life events and depressive symptoms in adolescence. METHOD: Three hundred and seventy-five young people (11-16 years) completed the Prospective Imagery Task, and self-reported on symptoms of anxiety and depression. They were also asked to describe a past negative life event they had been thinking about or imagining over the last seven days, which was subsequently coded by a clinician over whether it was no, low, moderate or high impact. RESULTS: Symptoms of depression were associated with less vivid positive imagery and more vivid negative imagery whether past or future, whilst symptoms of anxiety were associated with increased vividness for past negative events only. The relationship between life event severity and depression was increased for those with poorer vividness for positive future events. LIMITATIONS: These data were collected at a single time-point only, limiting conclusions on temporal relationships. All measures were also self-reported, increasing shared method variance. CONCLUSIONS: These findings suggest that the relationship between negative life events and prospective positive imagery are specific to depressive symptoms in adolescence and provide foundations for novel approaches to strengthen psychological interventions.

Using real-time fMRI to influence effective connectivity in the developing emotion regulation network.

For most people, adolescence is synonymous with emotional turmoil and it has been shown that early difficulties with emotion regulation can lead to persistent problems for some people. This suggests that intervention during development might reduce long-term negative consequences for those individuals. Recent research has highlighted the suitability of real-time fMRI-based neurofeedback (NF) in training emotion regulation (ER) networks in adults. However, its usefulness in directly influencing plasticity in the maturing ER networks remains unclear. Here, we used NF to teach a group of 17 7-16 year-olds to up-regulate the bilateral insula, a key ER region. We found that all participants learned to increase activation during the up-regulation trials in comparison to the down-regulation trials. Importantly, a subsequent Granger causality analysis of Granger information flow within the wider ER network found that during up-regulation trials, bottom-up driven Granger information flow increased from the amygdala to the bilateral insula and from the left insula to the mid-cingulate cortex, supplementary motor area and the inferior parietal lobe. This was reversed during the down-regulation trials, where we observed an increase in top-down driven Granger information flow to the bilateral insula from mid-cingulate cortex, pre-central gyrus and inferior parietal lobule. This suggests that: 1) NF training had a differential effect on up-regulation vs down-regulation network connections, and that 2) our training was not only superficially concentrated on surface effects but also relevant with regards to the underlying neurocognitive bases. Together these findings highlight the feasibility of using NF in children and adolescents and its possible use for shaping key social cognitive networks during development.

Fear conditioning in adolescents with anxiety disorders: results from a novel experimental paradigm.

OBJECTIVE: Considerable research examines fear conditioning in adult anxiety disorders but few studies examine youths. Adult data suggest that anxiety disorders involve elevated fear but intact differential conditioning. We used a novel paradigm to assess fear conditioning in pediatric anxiety patients. METHOD: Sixteen individuals with anxiety disorders and 38 healthy comparisons viewed two photographs of actresses displaying neutral expressions. One picture served as the conditioned stimulus (CS), paired with a fearful expression and a shrieking scream (CS+), whereas the other picture served as a CS unpaired with the aversive outcome (CS-). Conditioning was indexed by self-reported fear. Subjects participated in two visits involving conditioning and extinction trials. RESULTS: Both groups developed greater fear of the CS+ relative to CS-. Higher fear levels collapsed across each CS characterized anxious relative to healthy subjects, but no significant interaction between group and stimulus type emerged. Fear levels at visit 1 predicted avoidance of visit 2. Fear levels to both CS types showed stability even after extinction. CONCLUSIONS: Consistent with adult data, pediatric anxiety involves higher fear levels following conditioning but not greater differential conditioning. Extending these methods to neuroimaging studies may elucidate neural correlates of fear conditioning. Implications for exposure therapies are discussed.