Reflecting on imagery: a clinical perspective and overview of the special issue of memory on mental imagery and memory in psychopathology

The authors provide an overview of the papers in the special issue of Memory on mental imagery and memory in psychopathology. The papers address emotional, intrusive mental imagery across a range of psychological disorders including post-traumatic stress disorder (PTSD), agoraphobia, body dysmorphic disorder, mood disorders, and psychosis. They include work on information processing issues including modelling cravings, conditioning, and aversions, as well as imagery qualities such as vividness and emotionality. The overview aims to place the articles in a broader context and draw out some exciting implications of this novel work. It provides a clinical context to the recent growth in this area from a cognitive behavioural therapy (CBT) perspective. We begin with PTSD, and consider links to imagery in other disorders. The clinical implications stemming from this empirical work and from autobiographical memory theory are discussed. These include consideration of a variety of techniques for eliminating troublesome imagery, and creating healthy, realistic alternatives.     

情绪障碍及其干预:心理表象的视角

心理表象在多种情绪障碍中均表现出病理性特点。研究者基于心理表象主要对创伤后应激障碍、抑郁心境、双相障碍情绪和社交焦虑进行了心理病理学解释,尤其关注闪回和过度概化记忆等两种典型症状,并且重视心理表象在情绪症状维持中的作用。概括而言,研究者强调记忆形成与提取过程的异常、认知与行为的保护性策略的负强化、对事件及自我的认知偏差等三类因素对情绪障碍的致病作用。目前,针对或运用心理表象的干预与训练方法包括减少消极表象、改变消极表象内容、提高积极表象能力、提高记忆的具体性等四类。未来应注重侵入性表象的功能分析以及相关的心理病理学模型研究,并拓展干预与训练研究。     

Mental imagery as an emotional amplifier: application to bipolar disorder

Cognitions in the form of mental images have a more powerful impact on emotion than their verbal counterparts. This review synthesizes the cognitive science of imagery and emotion with transdiagnostic clinical research, yielding novel predictions for the basis of emotional volatility in bipolar disorder. Anxiety is extremely common in patients with bipolar disorder and is associated with increased dysfunction and suicidality, yet it is poorly understood and rarely treated. Mental imagery is a neglected aspect of bipolar anxiety although in anxiety disorders such as posttraumatic stress disorder and social phobia focusing on imagery has been crucial for the development of cognitive behavior therapy (CBT).In this review we present a cognitive model of imagery and emotion applied to bipolar disorder. Within this model mental imagery amplifies emotion, drawing on Clark's cyclical panic model [(1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461–470]. We (1) emphasise imagery's amplification of anxiety (cycle one); (2) suggest that imagery amplifies the defining (hypo-) mania of bipolar disorder (cycle two), whereby the overly positive misinterpretation of triggers leads to mood elevation (escalated by imagery), increasing associated beliefs, goals, and action likelihood (all strengthened by imagery).Imagery suggests a unifying explanation for key unexplained features of bipolar disorder: ubiquitous anxiety, mood instability and creativity. Introducing imagery has novel implications for bipolar treatment innovation - an area where CBT improvements are much-needed.     

Characteristics of autobiographical memories and prospective imagery across a spectrum of hypomanic personality traits

Evidence of a strong causal relationship between mental imagery and emotion has informed psychological conceptualisations of disordered positive mood states (i.e., mania). Holmes et al.'s cognitive model of bipolar disorder asserts a prominent role for intrusive and affect-laden positive imagery of the past and the future in the amplification and maintenance of positive mood and associated manic behaviours. The aims of the current study were two-fold: (1) to test aspects of this model in a non-clinical population sampled for hypomanic personality traits and (2) to examine the phenomenological characteristics of positive autobiographical memories and imagery of the future. Undergraduate students (N = 80) completed a battery of self-report questionnaires and rated their positive and negative memories and images of the future on a number of dimensions. We found significant positive correlations between hypomanic tendencies and the (1) everyday experience and use of mental imagery, (2) experience of intrusive mental imagery of future events, (3) emotional intensity and sensory detail of positive but not negative autobiographical memories. Results are discussed in the context of their theoretical and clinical implications, and directions for future research are considered.     

Attention,Memory, Intrusive Thoughts,and Acceptance in PTSD: An Update on the Empirical Literature for Clinicians

Information processing theory suggests that cognitive changes following trauma are common and hypothesized to have an impact on attention, memory, and intrusive thoughts. There is an ever-expanding empirical literature where cognitive features of posttraumatic stress disorder (PTSD) are being explored. However, it can sometimes be difficult for front-line clinicians to stay abreast of this literature and how it impacts the treatment s/he provides. The goal of this paper is to provide an overview of some recent basic and applied research on information processing in PTSD and the implications of these findings for cognitive-behavioral clinicians. In particular, we explore recent findings regarding attention, memory, intrusive thoughts/thought suppression, and acceptance as they relate to clinical work in patients with PTSD.     

Fantasy proneness, mental imagery and reality monitoring

Individual differences in fantasy proneness and vividness of mental imagery have been suggested to be related to source memory confusions. To test this hypothesis, two groups scoring either high or low on a measure of fantasy proneness (selected from a group of 231 subjects) were compared on measures of self report vividness of mental imagery, objective imagery ability and reality monitoring performance. The two groups differed significantly on ratings of imagery vividness (p<0.01), but not on the imagery performance tasks, nor on reality monitoring performance. Our results indicate that, although fantasy proneness is associated with experiences of vivid mental imagery, it does not necessarily lead to reality monitoring errors.     

A century of imagery research: reflections on Cheves Perky's contribution to our understanding of mental imagery

We review contemporary scientific research on the relationship between visual perception and visual mental imagery in the context of Cheves Perky's (1910) landmark article on imagery and imagination. This body of research has firmly established a strong connection between the psychology of imagery and perception and has contributed a strong voice to the imagery debate. We then use the concept of embodiment to discuss additional avenues of inquiry at which Perky's work hinted. These include a more thorough examination of the relationship between imagery and emotion, the creative, active aspects of imagery and imagination, and the methods we can bring to bear on understanding imagery and imagination as a human experience.     

Mental imagery and creativity: A meta‐analytic review study

The reports of many creative individuals suggest the use of mental imagery in scientific and artistic production. A variety of protocols have tested the association between mental imagery and creativity, but the individual differences approach has been most frequently employed. This approach is assessed here through a range of meta‐analytic tests. Database searches revealed 18 papers employing the individual differences approach that were subjected to a conservative set of selection criteria. Nine studies (1,494 participants) were included in the final analyses. A marginal, but statistically significant, Fisher's Z‐transformed correlation coefficient was revealed. Further analyses showed little difference between form and type of self‐reported imagery and divergent thinking. Explanations for the failure to account for more than 3% of the variance in the data sets are discussed in the context of anecdotal reports, task validity, and design problems.     

The developmental mental-disorder histories of adults with posttraumatic stress disorder: a prospective longitudinal birth cohort study

Clinical and epidemiologic studies have established that posttraumatic stress disorder (PTSD) is highly comorbid with other mental disorders. However, such studies have largely relied on adults' retrospective reports to ascertain comorbidity. The authors examined the developmental mental health histories of adults with PTSD using data on mental disorders assessed across the first 3 decades of life among members of the longitudinal Dunedin Multidisciplinary Health and Development Study; 100% of those diagnosed with past-year PTSD and 93.5% of those with lifetime PTSD at age 26 had met criteria for another mental disorder between ages 11 and 21. Most other mental disorders had first onsets by age 15. Of new cases of PTSD arising between ages 26 and 32, 96% had a prior mental disorder and 77% had been diagnosed by age 15. These data suggest PTSD almost always develops in the context of other mental disorders. Research on the etiology of PTSD may benefit from taking lifetime developmental patterns of comorbidity into consideration. Juvenile mental-disorder histories may help indicate which individuals are most likely to develop PTSD in populations at high risk of trauma exposure.     

Personality differences in mental imagery and the effects on verbal memory

This study examined the effects of extraversion and neuroticism on participants’ reported vividness of visual imagery and on their memory performance for concrete and abstract nouns. Groups of extraverts (n = 15) and introverts (n = 15) were selected from a larger original sample and asked to remember a series of concrete and abstract nouns, including a set of lexically ambiguous concrete homonyms (e.g., earth = 1. planet, 2. soil). Extraverts reported more vivid imagery than introverts but this did not translate into better recall for extraverts, even for concrete stimuli. Recall was best for unambiguous concrete nouns, followed by concrete homonyms, then abstract nouns. While initial analyses suggested that there was an interaction between extraversion and the type of word presented, later analyses revealed that neuroticism was the main driver in differences in recall between different word types. While differences in recall were best explained by context availability theory (Schwanenflugel, 1991) rather than dual coding theory (Paivio, 1991), questions remain about the power of either theory to explain the role of individual differences in personality on recall, particularly given that imagery vividness effects were related to extraversion while differences in recall were related to neuroticism. The implications of these findings for future research and theoretical development are discussed.     

Emotion-specific and emotion-non-specific components of posttraumatic stress disorder (PTSD): implications for a taxonomy of related psychopathology

Many cognitive theories of posttraumatic stress disorder (PTSD), including our own SPAARS model, propose that one basis of the disorder is the cognitive system's persistent failure to resolve discrepancies between trauma-related information and the content of pre-existing mental representations, such as schemas. This leads to the characteristic PTSD symptom pattern of re-experiencing and avoidance of trauma-related material. Furthermore, the nature of this unresolved discrepancy revolves around appraisals of threat and the corresponding emotion profile in PTSD is therefore predominantly intense fear and anxiety. This paper argues that this general framework can be extended to discrepancies around other appraisal dimensions such as loss, and consequently to other emotions such as sadness. A localized taxonomy is therefore proposed comprising emotional disorders that resemble PTSD in their basic patterns of re-experiencing and avoidance symptoms--what we call their 'emotion-non-specific component'--but that differ from PTSD in terms of the core emotions involved--what we call their 'emotion-specific component'. The clinical and nosological implications of this argument are discussed.     

The impact of depression and PTSD symptom severity on trauma memory

Posttraumatic stress disorder (PTSD) and depression frequently co-occur following a traumatic event. Differences in the processing of autobiographical memory have been observed in both disorders in the form of overgeneralised memories and negative intrusive memories. The current study examined how symptoms of PTSD and depression influence the phenomenological characteristics of trauma memories. Undergraduate students who had experienced a traumatic event (n?=?696) completed questionnaires online including measures of PTSD and depressive symptom severity. They rated their trauma memory on several phenomenological characteristics using the Memory Experiences Questionnaire [Sutin, A. R., &; Robins, R. W. (2007). Phenomenology of autobiographical memories: The memory experiences questionnaire. Memory.]. Moderated multiple regression was used to examine how PTSD and depressive symptom severity related to each phenomenological characteristic. Symptoms of PTSD and depression were related separately and uniquely to the phenomenological characteristics of the trauma memory. PTSD severity predicted trauma memories that were more negative, contained higher sensory detail, and were more vivid. In contrast, depressive symptom severity predicted trauma memories that were less accessible and less coherent. These findings suggest that depressive and PTSD symptomatology affect traumatic memory differently and support a distinction between these two disorders.     

Occurrence of imagery and its link with early memories in agoraphobia

Recent cognitive models suggest that mental imagery can help us understand the maintenance of anxiety disorders (e.g., de Silva, 1986; Hackmann, Surawy, & Clark, 1998). However, imagery is relatively unexplored within agoraphobia. Such images are also thought to be useful in uncovering memories that occurred around the onset of a disorder (Hackmann, Clark, & McManus, 2000). A total of 20 patients with agoraphobia and 20 matched controls took part in this investigation. Participants described any recurrent images they experienced in agoraphobic situations, and also any associated memories. All patients with agoraphobia (but no control participants) reported having distinct recurrent images in “agoraphobic situations”. Most images involved several sensory modalities and in the majority of cases appeared to be linked with unpleasant memories of events experienced many years previously. While these exploratory findings require replication, potential treatment implications are discussed.     

Prevalence of poor psychological morbidity following a minor road traffic accident (RTA): The clinical implications of a prospective longitudinal study

Few Road Traffic Accident (RTA) victims have their psychological needs attended to in hospital or afterwards. We conducted a small-scale preliminary investigation exclusively focussing on the prevalence of poor psychological morbidity following minor road traffic accidents (RTAs). Participants (N?=?50) completed assessments one-month after their minor RTA and (N?=?39) at 4-months follow-up. The identification of clinically significant anxiety, depression and post traumatic stress disorder (PTSD) in this minor RTA sample supports both evidence reported elsewhere and our specific predictions. Seven (14%) participants at baseline and five (12.8%) at follow-up met diagnostic criteria for PTSD. The clinical implications for identifying and meeting the psychological needs of minor RTA victims are discussed in the context of cognitive behavioural conceptualizations of mental disorder.     

Occurrence of imagery and its link with early memories in agoraphobia

Recent cognitive models suggest that mental imagery can help us understand the maintenance of anxiety disorders (e.g., de Silva, 1986; Hackmann, Surawy, & Clark, 1998). However, imagery is relatively unexplored within agoraphobia. Such images are also thought to be useful in uncovering memories that occurred around the onset of a disorder (Hackmann, Clark, & McManus, 2000). A total of 20 patients with agoraphobia and 20 matched controls took part in this investigation. Participants described any recurrent images they experienced in agoraphobic situations, and also any associated memories. All patients with agoraphobia (but no control participants) reported having distinct recurrent images in "agoraphobic situations". Most images involved several sensory modalities and in the majority of cases appeared to be linked with unpleasant memories of events experienced many years previously. While these exploratory findings require replication, potential treatment implications are discussed.     

Intrusive imagery in severe health anxiety: Prevalence, nature and links with memories and maintenance cycles

Increased understanding of the nature and role of intrusive imagery has contributed to the development of effective treatment protocols for some anxiety disorders. However, intrusive imagery in severe health anxiety (hypochondriasis) has been comparatively neglected. Hence, the current study investigates the prevalence, nature and content of intrusive imagery in 55 patients who met DSM-IV-TR (APA, 2000) criteria for the diagnosis of hypochondriasis. A semi-structured interview was used to assess the prevalence, nature and possible role of intrusive imagery in this disorder. Over 78% of participants reported experiencing recurrent, distressing intrusive images, the majority (72%) of which either were a memory of an earlier event or were strongly associated with a memory. The images tended to be future orientated, and were reliably categorised into four themes: i) being told ‘the bad news’ that you have a serious/life threatening-illness (6.9%), ii) suffering from a serious or life-threatening illness (34.5%), iii) death and dying due to illness (22.4%) and iv) impact of own death or serious illness on loved ones (36.2%). Participants reported responding to experiencing intrusive images by engaging in avoidance, checking, reassurance seeking, distraction and rumination. Potential treatment implications and links to maintenance cycles are considered.     

Representations in mental imagery and working memory: Evidence from different types of visual masks

Although few studies have systematically investigated the relationship between visual mental imagery and visual working memory, work on the effects of passive visual interference has generally demonstrated a dissociation between the two functions. In four experiments, we investigated a possible commonality between the two functions: We asked whether both rely on depictive representations. Participants judged the visual properties of letters using visual mental images or pictures of unfamiliar letters stored in short-term memory. Participants performed both tasks with two different types of interference: sequences of unstructured visual masks (consisting of randomly changing white and black dots) or sequences of structured visual masks (consisting of fragments of letters). The structured visual noise contained elements of depictive representations (i.e., shape fragments arrayed in space), and hence should interfere with stored depictive representations; the unstructured visual noise did not contain such elements, and thus should not interfere as much with such stored representations. Participants did in fact make more errors in both tasks with sequences of structured visual masks. Various controls converged in demonstrating that in both tasks participants used representations that depicted the shapes of the letters. These findings not only constrain theories of visual mental imagery and visual working memory, but also have direct implications for why some studies have failed to find that dynamic visual noise interferes with visual working memory.     

干预条件性恐惧记忆表达的相关影响因素分析

创伤后应激障碍是个体经历严重应激后形成的一种焦虑障碍, 对其治疗的关键是熄灭由创伤应激导致的条件性恐惧记忆。条件性恐惧的动物模型研究发现恐惧记忆一旦获得后就难以熄灭, 容易复发, 而这一点也是PTSD的关键临床症状表现之一。因此, 如何更好更持久地熄灭恐惧记忆, 是一个具有重要理论和临床意义的研究热点。本文围绕促进恐惧记忆的长久消退和破坏恐惧记忆的再巩固两方面的行为或药理干预及机制进行综述。针对本文所述的几种基础实验处理, 临床上可以研究治疗创伤后应激障碍的相应疗法。     

Placing the mnemonic model in context: diagnostic, theoretical, and clinical considerations

The mnemonic model of posttraumatic stress disorder (PTSD) proposed by D. C. Rubin, D. Berntsen, and M. K. Bohni presents some provocative and potentially insightful ideas about this mental disorder. D. C. Rubin et al. suggested that PTSD is caused and maintained through a "pathogenic memory" (D. C. Rubin et al., 2008, p. 985) of a negative event rather than by exposure to a traumatic event per se. The present authors examine the mnemonic model in the context of relevant diagnostic, theoretical, and clinical considerations. Specifically, to evaluate the arguments and evidence provided in support of the mnemonic model of PTSD, the present authors focus on 4 issues: (a) problems inherent with comparing a theoretical model (i.e., the mnemonic model) with a diagnostic model (i.e., the DSM-IV-TR model), (b) problems with not comparing the mnemonic model with relevant cognitive and memory models of PTSD, (c) problems with the degree to which the research reviewed provides support for the mnemonic model, and (d) concerns that memory in PTSD is confounded with the basic disorder, rather than causing PTSD. The present authors conclude with suggestions for future theory and research to help differentiate between memory's role in the origins of PTSD and memory's role in the clinical course of the disorder.