The traces of imagination: early attention bias toward positively imagined stimuli.

Positively imagined activities may capture visual attention due to an increase in positive value. Increasing attention toward activities, in turn, may prove useful for clinical interventions aiming to motivate behavioral engagement. Employing a within-subject experimental design, we examined the effect of positive imagery on attention using a visual probe task with concurrent eye tracking. Adults from the general population (N = 54) imagined performing activities involving visually presented objects in a positive (focusing on the positive emotional impact) or neutral (focusing on a neutral circumstance) manner. They then completed a visual probe task using picture stimuli depicting one object per type of imagery. Positive compared to neutral imagery increased self-reported behavioral motivation and biased the direction, but not the duration, of gaze toward objects associated with the imagined activities. An exploratory analysis showed a positive association between the direction bias and depressive symptoms. Our findings build on existing literature on positive imagery as a motivational amplifier by highlighting early attention as an underlying cognitive mechanism.

Healthy cravings? Impact of imagined healthy food consumption on craving for healthy foods and motivation to eat healthily - Results of an initial experimental study.

Craving for high-calorie foods predicts consumption of high-calorie foods thereby contributing to unhealthy eating habits and, potentially in the long term, to the development of overweight, obesity, and eating disorder pathology. Thus, effective interventions tackling craving for unhealthy foods and motivating healthy eating behavior are needed. This initial study tested if an experimental mental imagery procedure could induce craving for healthy foods and increase the motivation to eat healthily. Participants (N = 82) were randomized to either a healthy craving mental imagery condition or to a neutral mental imagery control condition. Craving for healthy foods and motivation to eat healthily was assessed before and after the experimental manipulation via self-report. A (disguised) food choice for healthy versus unhealthy food was added as a behavioural measure at the end of the experiment. Repeated measures of variance analyses with time (pre vs. post experimental manipulation) and condition (healthy craving mental imagery versus neutral mental imagery) yielded significant interactions for healthy craving and motivation to eat healthily: Post-hoc tests showed that craving for healthy foods and motivation to eat healthily increased significantly after the experimental manipulation in the healthy craving mental imagery condition, but not in the neutral mental imagery condition. Results of this initial study suggest that an experimental mental imagery induction of craving for healthy food leads to an increase in healthy craving and motivation to eat healthily. Further experimental research is needed to rule out priming effects, to test the underlying mechanisms of this effect, and evaluate the potential of this mental imagery procedure in a clinical context.

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.

Imagery rescripting in individuals with binge-eating behavior: An experimental proof-of-concept study.

OBJECTIVE: Mental imagery is more strongly related to emotions than verbal cognitions. Binge eating is associated with dysfunctional emotional regulation. However, cognitive therapy techniques have focused on verbal cognitions. This proof-of-concept study compares a traditional cognitive therapy technique, cognitive restructuring (CR), with imagery rescripting (IR) in individuals with binge-eating disorder or bulimia nervosa. METHOD: Thirty-six participants were asked to recall an idiosyncratic mental image of social rejection. They were then randomly assigned to a single session of CR or IR. Ratings of positive and negative emotions, and impact on rational and emotional core beliefs were administered prior to and after imagery recall, after the experimental intervention, and 1 week later. Eating disorder psychopathology was measured before and 1 week after the experimental intervention. RESULTS: Repeated measures ANOVAs revealed that after the experimental intervention, negative emotions and core beliefs had significantly decreased in CR and IR. Both groups also showed an increase in positive emotions that lasted until 1-week follow-up. DISCUSSION: This study suggests that CR and IR as an experimental intervention have comparable impact on distress and rational and emotional core beliefs. The feasibility of IR has been demonstrated. The effect of imagery recall on CR needs further investigation.

An investigation of mental imagery in bipolar disorder: Exploring "the mind's eye".

OBJECTIVES: Mental imagery abnormalities occur across psychopathologies and are hypothesized to drive emotional difficulties in bipolar disorder (BD). A comprehensive assessment of mental imagery in BD is lacking. We aimed to test whether (i) mental imagery abnormalities (abnormalities in cognitive stages and subjective domains) occur in BD relative to non-clinical controls; and (ii) to determine the specificity of any abnormalities in BD relative to depression and anxiety disorders. METHODS: Participants included 54 subjects in the BD group (depressed/euthymic; n=27 in each subgroup), subjects with unipolar depression (n=26), subjects with anxiety disorders (n=25), and non-clinical controls (n=27) matched for age, gender, ethnicity, education, and premorbid IQ. Experimental tasks assessed cognitive (non-emotional) measures of mental imagery (cognitive stages). Questionnaires, experimental tasks, and a phenomenological interview assessed subjective domains including spontaneous imagery use, interpretation bias, and emotional mental imagery. RESULTS: (i) Compared to non-clinical controls, the BD combined group reported a greater impact of intrusive prospective imagery in daily life, more vivid and "real" negative images (prospective imagery task), and higher self-involvement (picture-word task). The BD combined group showed no clear abnormalities in cognitive stages of mental imagery. (ii) When depressed individuals with BD were compared to the depressed or anxious clinical control groups, no significant differences remained-across all groups, imagery differences were associated with affective lability and anxiety. CONCLUSIONS: Compared to non-clinical controls, BD is characterized by abnormalities in aspects of emotional mental imagery within the context of otherwise normal cognitive aspects. When matched for depression and anxiety, these abnormalities are not specific to BD-rather, imagery may reflect a transdiagnostic marker of emotional psychopathology.

Mental Imagery in Depression: Phenomenology, Potential Mechanisms, and Treatment Implications.

Mental imagery is an experience like perception in the absence of a percept. It is a ubiquitous feature of human cognition, yet it has been relatively neglected in the etiology, maintenance, and treatment of depression. Imagery abnormalities in depression include an excess of intrusive negative mental imagery; impoverished positive imagery; bias for observer perspective imagery; and overgeneral memory, in which specific imagery is lacking. We consider the contribution of imagery dysfunctions to depressive psychopathology and implications for cognitive behavioral interventions. Treatment advances capitalizing on the representational format of imagery (as opposed to its content) are reviewed, including imagery rescripting, positive imagery generation, and memory specificity training. Consideration of mental imagery can contribute to clinical assessment and imagery-focused psychological therapeutic techniques and promote investigation of underlying mechanisms for treatment innovation. Research into mental imagery in depression is at an early stage. Work that bridges clinical psychology and neuroscience in the investigation of imagery-related mechanisms is recommended.

Interpersonal problems, dependency, and self-criticism in major depressive disorder.

OBJECTIVES: The goal of the present research was the examination of overlap between 2 research traditions on interpersonal personality traits in major depression. We hypothesized that Blatt's (2004) dimensions of depressive experiences around the dimensions of relatedness (i.e., dependency) and self-definition (i.e., self-criticism) are associated with specific interpersonal problems according to the interpersonal circumplex model (Leary, 1957). In addition, we examined correlations of interpersonal characteristics with depression severity. METHOD: Analyses were conducted on 283 patients with major depressive disorder combined from 2 samples. Of the patients, 151 participated in a randomized controlled trial in the United States, and 132 patients were recruited in an inpatient unit in Germany. Patients completed measures of symptomatic distress, interpersonal problems, and depressive experiences. RESULTS: Dependency was associated with more interpersonal problems related to low dominance and high affiliation, while self-criticism was associated with more interpersonal problems related to low affiliation. These associations were independent of depression severity. Self-criticism showed high overlap with cognitive symptoms of depression. CONCLUSION: The findings support the interpersonal nature of Blatt's dimensions of depressive experiences. Self-criticism is associated with being too distant or cold toward others as well as greater depression severity, but is not related to the dimension of dominance.

Self-reported psychotic-like experiences are a poor estimate of clinician-rated attenuated and frank delusions and hallucinations.

BACKGROUND: One reason for the decision to delay the introduction of an Attenuated Psychosis Syndrome in the main text of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders was the concern that attenuated psychotic symptoms (APS) might in fact be common features in adolescents and young adults from the general population of no psychopathological significance in themselves. This concern was based on reports of high prevalence rates of psychotic-like experiences (PLEs) in the general population and the assumption that PLEs are a good estimate of APS. Although the criterion validity of self-reported PLEs had already been studied with respect to clinician-rated psychotic symptoms and found insufficient, it had been argued that PLEs might in fact be more comparable with mild, subclinical expressions of psychotic symptoms and, therefore, with APS. The present paper is the first to specifically study this assumption. SAMPLING AND METHODS: The sample consisted of 123 persons seeking help at a service for the early detection of psychosis, of whom 54 had an at-risk mental state or psychosis, 55 had a nonpsychotic mental disorder and 14 had no full-blown mental disorder. PLEs were assessed with the Peters Delusion Inventory and the revised Launay-Slade Hallucination Scale, and psychotic symptoms and APS were assessed with the Structured Interview for Prodromal Syndromes. RESULTS: At a level of agreement between the presence of any PLE (in 98.4% of patients) and any APS (in 40.7%) just exceeding chance (κ = 0.022), the criterion validity of PLEs for APS was insufficient. Even if additional qualifiers (high agreement or distress, preoccupation and conviction) were considered, PLEs (in 52.8%) still tended to significantly overestimate APS, and agreement was only fair (κ = 0.340). Furthermore, the group effect on PLE prevalence was, at most, moderate (Cramer's V ≤ 0.382). CONCLUSIONS: The prevalence of APS cannot be deduced from studies of PLEs. Thus, the high population prevalence rate of PLEs does not allow the conclusion that APS are common features of no pathological significance and would lack clinical validity as an Attenuated Psychosis Syndrome in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Rather, the population prevalence rate of APS has to be assumed to be largely unknown at present but is likely lower than indicated by epidemiological studies of PLEs. Therefore, dedicated studies are warranted, in which APS are assessed in a way that equates to their clinical evaluation.

From anticipation to action: A RCT on mental imagery exercises in daily life as a motivational amplifier for individuals with depressive symptoms.

Encouraging engagement in rewarding or pleasant activities is one of the most important treatment goals for depression. Mental imagery exercises have been shown to increase the motivation for planned behaviour in the lab but it is unclear whether this is also the case in daily life. Therefore, we aimed to investigate the effect of mental imagery exercises on motivation and behaviour in daily life. Participants with depressive symptoms (N = 59) were randomly assigned to a group receiving mental imagery (MI) exercises or a control group receiving relaxation (RE) exercises via study phones. We employed an experience sampling design with 10 assessments per day for 10 days (three days baseline, four days with two exercises per day and three days post-intervention). Data was analysed using t-tests and multilevel linear regression analyses. As predicted, MI exercises enhanced motivation and reward anticipation during the intervention phase compared to RE. However, MI did not enhance active behaviour or strengthen the temporal association from reward anticipation (t-1) to active behaviour (t). Mental imagery exercises can act as a motivational amplifier but its effects on behaviour and real-life reward processes remain to be elucidated.

Behavioural activation v. antidepressant medication for treating depression in Iran: randomised trial.

BACKGROUND: Behavioural activation might be a viable alternative to antidepressant medication for major depressive disorder. AIMS: To compare the effectiveness of behavioural activation and treatment as usual (TAU, antidepressant medication) for major depressive disorder in routine clinical practice in Iran. METHOD: Patients with major depressive disorder (n = 100) were randomised to 16 sessions of behavioural activation (n = 50) or antidepressant medication (n = 50) (IRCT138807192573N1). The main outcome was depression, measured with the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD), assessed at 0, 4, 13 and 49 weeks. RESULTS: Symptom reduction was greater in the behavioural activation group than in the TAU group on both the BDI and the HRSD at 13 and 49 weeks in multilevel analysis. Baseline depression severity was a moderator, with relatively better effects for behavioural activation in individuals who were more severely depressed. Also, there was better retention in the behavioural activation than in the TAU group. CONCLUSIONS: Behavioural activation is a viable and effective treatment for people with major depressive disorder, especially for those who are more severely depressed, and it can successfully be disseminated into routine practice settings in a non-Western country such as Iran.

Skill Improvement Through Learning in Therapy (SKILT): A Study Protocol for a Randomized Trial Testing the Direct Effects of Cognitive Behavioral Therapy Skill Acquisition and Role of Learning Capacity in Depression.

Background: To improve psychological treatments for major depressive disorder (MDD), a better understanding on how symptoms ameliorate during treatment is essential. In cognitive behavioral therapy (CBT), it is unclear whether procedures focused on the acquisition of CBT skills play a causal role in the improvement of CBT skills. In this randomized trial, we isolate a single CBT Skill Acquisition Procedure (CBTSAP) and test its direct effects on CBT skills and related therapy processes (i.e., change in (idiosyncratic) dysfunctional thinking and reward processing). We hypothesize that the CBTSAP causes improvements in CBT skills and related therapy processes compared to an active control condition. In addition, we hypothesize that individual differences in attentional bias and memory functioning (defined as learning capacity) moderate the effects of CBTSAP on outcomes and that using mental imagery as a cognitive support strategy to strengthen the effects of the CBTSAP will be most beneficial for patients with low learning capacity. Method: 150 patients with MDD will be randomized to one of three conditions: 1. an active control condition, 2. CBTSAP, 2. CBTSAP plus mental imagery, all consisting of three sessions. Primary outcomes will be change in CBT skills, changes in (idiosyncratic) dysfunctional thoughts and behaviors, reward processing. Depressive symptoms are a secondary outcome. Measures of learning capacity will be conducted at baseline and tested as a potential moderator. Discussion: Knowing whether and for whom the acquisition of CBT skills leads to change in therapy processes and a subsequent reduction of depressive symptoms will inform on how to personalize and optimize psychotherapy outcomes for depression. Trial registration: The trial is registered at the German Clinical Trial Register (DKTR; registration number: DRKS00024116).

Mechanistic pathways of change in twice weekly versus once weekly sessions of psychotherapy for depression.

BACKGROUND: Recently, we showed that twice weekly sessions of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for depression lead to better and faster treatment outcomes compared to once weekly sessions (Bruijniks et al., 2020). The present study investigated which pathways of change may account for the effects of different session frequencies. METHOD: The sample consisted of 200 patients who were randomized to CBT weekly, CBT twice weekly, IPT weekly, or IPT twice weekly. Outcome and therapy processes were measured at baseline, two weeks and monthly up to month 6 after the start of treatment. Latent change score models investigated temporal relations between change in therapy processes and change in depression and tested whether change in the therapy processes mediated the effect of session frequency on change in depression. RESULTS: IPT skills mediated the relation between session frequency and change in depression. A decrease in depression was related to subsequent improvement in CBT skills and subsequent decrease in motivation for therapy. CONCLUSION: The development of IPT skills may explain why a twice weekly higher session frequency is more effective in reducing depression compared to a once-weekly session frequency. Future studies should disentangle the causal effects of therapy process change throughout the course of therapy.

Prospective Mental Imagery in Depression: Impact on Reward Processing and Reward-Motivated Behaviour.

Background: Mental imagery has long been part of cognitive behavioural therapies. More recently, a resurgence of interest has emerged for prospective mental imagery, i.e. future-directed imagery-based thought, and its relation to reward processing, motivation and behaviour in the context of depression. Method: We conducted a selective review on the role of prospective mental imagery and its impact on reward processing and reward-motivated behaviour in depression. Results: Based on the current literature, we propose a conceptual mechanistic model of prospective mental imagery. Prospective mental imagery of engaging in positive activities can increase reward anticipation and reward motivation, which can transfer to increased engagement in reward-motivated behaviour and more experiences of reward, thereby decreasing depressive symptoms. We suggest directions for future research using multimodal assessments to measure the impact of prospective mental imagery from its basic functioning in the lab to real-world and clinical implementation. Conclusion: Prospective mental imagery has the potential to improve treatment for depression where the aim is to increase reward-motivated behaviours. Future research should investigate how exactly and for whom prospective mental imagery works.

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.

Dutch courage? Effects of acute alcohol consumption on self-ratings and observer ratings of foreign language skills.

AIMS: A popular belief is that alcohol improves the ability to speak in a foreign language. The effect of acute alcohol consumption on perceived foreign language performance and actual foreign language performance in foreign language learners has not been investigated. The aim of the current study was to test the effects of acute alcohol consumption on self-rated and observer-rated verbal foreign language performance in participants who have recently learned this language. METHODS: Fifty native German speakers who had recently learned Dutch were randomized to receive either a low dose of alcohol or a control beverage that contained no alcohol. Following the experimental manipulation, participants took part in a standardized discussion in Dutch with a blinded experimenter. The discussion was audio-recorded and foreign language skills were subsequently rated by two native Dutch speakers who were blind to the experimental condition (observer-rating). Participants also rated their own individual Dutch language skills during the discussion (self-rating). RESULTS: Participants who consumed alcohol had significantly better observer-ratings for their Dutch language, specifically better pronunciation, compared with those who did not consume alcohol. However, alcohol had no effect on self-ratings of Dutch language skills. CONCLUSIONS: Acute alcohol consumption may have beneficial effects on the pronunciation of a foreign language in people who have recently learned that language.

Psychophysiological reactivity, coping behaviour and intrusive memories upon multisensory Virtual Reality and Script-Driven Imagery analogue trauma: A randomised controlled crossover study.

BACKGROUND: Peri- and post-traumatic factors predict the differential development of stress-associated mental disorders. Prospective designs assessing these risk factors in real-time under controlled experimental conditions can overcome limitations of retrospective designs. Therefore, we aimed to investigate multi-sensory, experimental analogues of a traumatic experience delivered in Virtual Reality (VR) or Script-Driven Imagery (SDI). METHODS: In a randomised controlled crossover design, differences in the induced analogue trauma symptoms between multi-sensory analogue trauma by either VR or SDI versus a neutral condition were assessed in 127 non-clinical participants. RESULTS: Analogue symptoms (psychophysiological responses, coping behaviour and intrusive memories of the experimental trauma) increased following analogue trauma in both VR and SDI, with more analogue symptoms for VR. Psychophysiological arousal was in general higher in VR. LIMITATIONS: The analogue trauma situation of a car park fire that was used may be infrequent in real life. CONCLUSIONS: Multisensory (vision, olfaction, hearing) analogue trauma in VR and SDI offers a useful tool for the induction and real-time assessment of peri- and post-traumatic risk factors for analogue stress-associated psychopathology. VR was more effective in inducing analogue symptoms than SDI, even though the latter might be more personalised. New experimental models for studying trauma exposure and responses may contribute to a better understanding of risk factors and help to identify and protect individuals at risk.

Exploring mechanisms of change in schema therapy for chronic depression.

BACKGROUND AND OBJECTIVES: The underlying mechanisms of symptom change in schema therapy (ST) for chronic major depressive disorder (cMDD) have not been studied. The aim of this study was to explore the impact of two potentially important mechanisms of symptom change, maladaptive schemas (proxied by negative idiosyncratic core-beliefs) and the therapeutic alliance. METHODS: We drew data from a single-case series of ST for cMDD. Patients with cMDD (N = 20) received on average 78 repeated weekly assessments over a course of up to 65 individual sessions of ST. Focusing on repeated assessments within-individuals, we used mixed regression to test whether change in core-beliefs and therapeutic alliance preceded, followed, or occurred concurrently with change in depressive symptoms. RESULTS: Changes in core-beliefs did not precede but were concurrently related to changes in symptoms. Repeated goal and task agreement ratings (specific aspects of alliance) of the same session, completed on separate days, were at least in part associated with concurrent changes in symptoms. LIMITATIONS: By design this study had a small sample-size and no control group. CONCLUSIONS: Contrary to what would be expected based on theory, our findings suggest that change in core-beliefs does not precede change in symptoms. Instead, change in these variables occurs concurrently. Moreover, alliance ratings seem to be at least in part colored by changes in current mood state.

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.