The IBER study: a feasibility randomised controlled trial of imagery based emotion regulation for the treatment of anxiety in bipolar disorder.

BACKGROUND: Intrusive mental imagery is associated with anxiety and mood instability within bipolar disorder and therefore represents a novel treatment target. Imagery Based Emotion Regulation (IBER) is a brief structured psychological intervention developed to enable people to use the skills required to regulate the emotional impact of these images. METHODS: Participants aged 18 and over with a diagnosis of bipolar disorder and at least a mild level of anxiety were randomly assigned (1:1) to receive IBER plus treatment as usual (IBER + TAU) or treatment as usual alone (TAU). IBER was delivered in up to 12 sessions overs 16 weeks. Clinical and health economic data were collected at baseline, end of treatment and 16-weeks follow-up. Objectives were to inform the recruitment process, timeline and sample size estimate for a definitive trial and to refine trial procedures. We also explored the impact on participant outcomes of anxiety, depression, mania, and mood stability at 16-weeks and 32-weeks follow-up. RESULTS: Fifty-seven (28: IBER + TAU, 27: TAU) participants from two sites were randomised, with 50 being recruited within the first 12 months. Forty-seven (82%) participants provided outcome data at 16 and 32-weeks follow-up. Thirty-five participants engaged in daily mood monitoring at the 32-week follow-up stage. Retention in IBER treatment was high with 27 (96%) attending ≥ 7 sessions. No study participants experienced a serious adverse event. DISCUSSION: The feasibility criteria of recruitment, outcome completion, and intervention retention were broadly achieved, indicating that imagery-focused interventions for bipolar disorder are worthy of further investigation.

The phenomenology of mental imagery in people with intellectual disabilities.

OBJECTIVES: Mental imagery is important in the development and maintenance of psychological disorders and well-being but has been neglected in people with intellectual disabilities. A detailed idiographic analysis of the lived experience of mental imagery in this population is presented. DESIGN: This qualitative study uses interpretative phenomenological analysis (IPA). It involved inclusive research methods with people with intellectual disabilities and other stakeholders (including family members, advocates, support workers and intellectual disability service managers). METHODS: Ten individual semi-structured interviews were conducted with people with mild-moderate intellectual disabilities. Participants were opportunistically sampled through organisations providing community services to people with intellectual disabilities in the UK. Two men and eight women (mean age 43 years) participated. Interviews were audio-recorded and analysed using IPA. RESULTS: People with intellectual disabilities are able to experience a range of rich and detailed mental images across all sensory modalities. Participants reported changes in affect based on mental imagery, and an ability to experience both spontaneous and deliberate mental images. The emotional saliency of the object of mental imagery appeared to influence participants' ability to engage with imagery. A number of adaptations make mental imagery more accessible and easier to report. The ability of people with intellectual disabilities to experience vivid mental imagery has important clinical implications for the use of a range of mental imagery interventions with this population. CONCLUSIONS: The need to consider mental imagery interventions for this population, and how these can be adapted to ensure accessibility is a priority for people with intellectual disabilities and psychological disorders.

A systematic review and narrative synthesis of mental imagery tasks in people with an intellectual disability: Implications for psychological therapies.

Mental imagery is recognised for its role in both psychological distress and wellbeing, with mental imagery techniques increasingly being incorporated into psychological interventions. In this systematic review and narrative synthesis (PROSPERO 2021: CRD42021240930), we identify and evaluate the evidence base for the phenomenon and phenomenology of mental imagery in people with intellectual disabilities, to ascertain the applicability of such interventions for this population. Electronic searches of nine databases and grey literature identified relevant publications. Two reviewers independently assessed titles and abstracts of retrieved records (n = 8609) and full-text articles (n = 101) against eligibility criteria. Data were extracted and quality appraised. Forty-onepapers met our eligibility criteria. The quality and designs were variable. Mental imagery was facilitated through ensuring participants understood tasks, providing opportunity to rehearse tasks (including using concrete prompts) and using scaffolding to help participants elaborate their responses. People with intellectual disabilities can engage with mental imagery, with appropriate adaptations, although the associated phenomenology has not been thoroughly investigated. Mental imagery interventions may be useful for people with intellectual disabilities with appropriate modifications.

Targeting intrusive imagery using a competing task technique: a case study.

BACKGROUND: Even in cases with complexity, simple techniques can be useful to target a specific symptom. Intrusive mental images are highly disruptive, drive emotion, and contribute to maintaining psychopathology. Cognitive science suggests that we might target intrusive images using competing tasks. AIMS: We describe an imagery competing task technique within cognitive behavioural therapy (CBT) with a patient with bipolar disorder and post-traumatic stress disorder (PTSD) symptoms. The intervention - including Tetris computer game-play - was used (1) to target a specific image within one therapy session, and (2) to manage multiple images in daily life. METHOD: A single case (AB) design was used. (1) To target a specific image, the patient brought the image to mind and, after mental rotation instructions and game-play practice, played Tetris for 10 minutes. Outcomes, pre- and post-technique, were: vividness/distress ratings when the image was brought to mind; reported intrusion frequency over a week. (2) To manage multiple images, the patient used the intervention after an intrusive image occurred. Outcomes were weekly measures of: (a) imagery characteristics; (b) symptoms of PTSD, anxiety, depression and mania. RESULTS: (1) For the target image, there were reductions in vividness (80% to 40%), distress (70% to 0%), and intrusion frequency (daily to twice/week). (2) For multiple images, there were reductions from baseline to follow-up in (a) imagery vividness (38%), realness (66%) and compellingness (23%), and (b) PTSD symptoms (Impact of Events Scale-Revised score 26.33 to 4.83). CONCLUSION: This low-intensity intervention aiming to directly target intrusive mental imagery may offer an additional, complementary tool in CBT.

Imagery-Focused Cognitive Therapy (ImCT) for Mood Instability and Anxiety in a Small Sample of Patients with Bipolar Disorder: a Pilot Clinical Audit.

BACKGROUND: Despite the global impact of bipolar disorder (BD), treatment success is limited. Challenges include syndromal and subsyndromal mood instability, comorbid anxiety, and uncertainty around mechanisms to target. The Oxford Mood Action Psychology Programme (OxMAPP) offered a novel approach within a cognitive behavioural framework, via mental imagery-focused cognitive therapy (ImCT). AIMS: This clinical audit evaluated referral rates, clinical outcomes and patient satisfaction with the OxMAPP service. METHOD: Eleven outpatients with BD received ImCT in addition to standard psychiatric care. Mood data were collected weekly from 6 months pre-treatment to 6 months post-treatment via routine mood monitoring. Anxiety was measured weekly from start of treatment until 1 month post-treatment. Patient feedback was provided via questionnaire. RESULTS: Referral and treatment uptake rates indicated acceptability to referrers and patients. From pre- to post-treatment, there was (i) a significant reduction in the duration of depressive episode relapses, and (ii) a non-significant trend towards a reduction in the number of episodes, with small to medium effect size. There was a large effect size for the reduction in weekly anxiety symptoms from assessment to 1 month follow-up. Patient feedback indicated high levels of satisfaction with ImCT, and underscored the importance of the mental imagery focus. CONCLUSIONS: This clinical audit provides preliminary evidence that ImCT can help improve depressive and anxiety symptoms in BD as part of integrated clinical care, with high patient satisfaction and acceptability. Formal assessment designs are needed to further test the feasibility and efficacy of the new ImCT treatment on anxiety and mood instability.

Caring For Me and You: the co-production of a computerised cognitive behavioural therapy (cCBT) package for carers of people with dementia.

OBJECTIVES: Carers of people with dementia face barriers in accessing therapy for mental health difficulties. Computerised cognitive behavioural therapy (cCBT) packages can be effective in treating a range of presentations; however, tailored packages for carers' unique needs are lacking. Our aim was to design a cCBT package for carers to address the limitations of previous online interventions, by including users and experts as consultants and collaborators throughout the project. METHOD: We adopted a three-phase approach to the development process. Firstly, a data-gathering phase in which current literature and best practice was reviewed, and semi-structured interviews conducted with service users, academic and clinical experts. Secondly, a co-production and refinement phase with carers testing materials and providing feedback. Thirdly, a pilot field testing phase of service users and the research team testing the package. RESULTS: The 'Caring For Me and You' package adopted a transdiagnostic approach to take account of the range of difficulties that carers face. The package consisted of 20 short sessions with features built in to engage users and personalise content to meet individuals' needs. CONCLUSION: User involvement was central to the design of the 'Caring For Me and You' package which is currently being evaluated in a three-arm randomised controlled trial.

Cognitions in bipolar affective disorder and unipolar depression: imagining suicide.

OBJECTIVE: Bipolar disorder has the highest rate of suicide of all the psychiatric disorders. In unipolar depression, individuals report vivid, affect-laden images of suicide or the aftermath of death (flashforwards to suicide) during suicidal ideation but this phenomenon has not been explored in bipolar disorder. Therefore the authors investigated and compared imagery and verbal thoughts related to past suicidality in individuals with bipolar disorder (n = 20) and unipolar depression (n = 20). METHODS: The study used a quasi-experimental comparative design. The Structured Clinical Interview for DSM-IV was used to confirm diagnoses. Quantitative and qualitative data were gathered through questionnaire measures (e.g., mood and trait imagery use). Individual interviews assessed suicidal cognitions in the form of (i) mental images and (ii) verbal thoughts. RESULTS: All participants reported imagining flashforwards to suicide. Both groups reported greater preoccupation with these suicide-related images than with verbal thoughts about suicide. However, compared to the unipolar group, the bipolar group were significantly more preoccupied with flashforward imagery, rated this imagery as more compelling, and were more than twice as likely to report that the images made them want to take action to complete suicide. In addition, the bipolar group reported a greater trait propensity to use mental imagery in general. CONCLUSIONS: Suicidal ideation needs to be better characterized, and mental imagery of suicide has been a neglected but potentially critical feature of suicidal ideation, particularly in bipolar disorder. Our findings suggest that flashforward imagery warrants further investigation for formal universal clinical assessment procedures.