Intrusive imagery in anxiety disorders in adolescents

Background: Mental imagery plays an important role in models of anxiety disorders in adults. This understanding rests on qualitative and quantitative studies. Qualitative studies of imagery in anxious adolescents have not been reported in the literature. Aims: To address this gap, we aimed to explore adolescents’ experiences of spontaneous imagery in the context of anxiety disorders. Method: We conducted one-to-one semi-structured interviews, with 13 adolescents aged 13–17 years with a DSM-5 anxiety disorder, regarding their experiences of spontaneous imagery. We analysed participants’ responses using thematic analysis. Results: We identified five superordinate themes relating to adolescents’ influences on images, distractions from images, controllability of images, emotional responses to imagery and contextual influences on imagery. Conclusions: Our findings suggest that spontaneous images are an important phenomenon in anxiety disorders in adolescents, associated with negative emotions during and after their occurrence. Contextual factors and adolescents’ own cognitive styles appear to influence adolescents’ experiences of images in anxiety disorders.

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.

Intrusive imagery in adolescent anxiety disorders

Background: Mental imagery plays an important role in models of anxiety disorders in adults. This understanding rests on qualitative and quantitative studies. Qualitative studies of imagery in anxious adolescents have not been reported in the literature. Aims: To address this gap, we aimed to explore adolescents’ experiences of spontaneous imagery in the context of anxiety disorders.Method: We conducted one-to-one semi-structured interviews, with 13 adolescents aged 13-17 years with a DSM-5 anxiety disorder, regarding their experiences of spontaneous imagery. We analysed participants’ responses using thematic analysis.Results: We identified five super-ordinate themes relating to adolescents’ influences on images, distractions from images, controllability of images, emotional responses to imagery and contextual influences on imagery. Conclusions: Our findings suggest spontaneous images are an important phenomenon in anxiety disorders in adolescents, associated with negative emotions during and after their occurrence. Contextual factors and adolescents’ own cognitive styles appear to influence adolescents’ experiences of images in anxiety disorders.

Looking on the bright side and seeing it vividly: interpretation bias and involuntary mental imagery are related to risk for bipolar disorder

Background:Involuntary mental imagery is elevated among people with bipolar disorder, and has been shown to shape biases in interpretation of ambiguous information. However, it is not clear whether biases in interpretation of ambiguous scenarios can be observed in those at risk for bipolar disorder, or whether involuntary imagery is related to such a bias.Aims:In the present study, we extended a prominent model of bipolar cognition to an at-risk sample. We specifically tested whether positive interpretation bias and involuntary mental imagery are linked to a greater risk of bipolar disorder.Method:Young adults (N = 169) completed measures of risk for bipolar disorder (the Hypomanic Personality Scale [HPS]), interpretation bias, and involuntary mental imagery.Results:Higher scores on the HPS were significantly correlated with more positive interpretations of ambiguous scenarios (β = 0.29, p <. 01) and more frequent involuntary mental imagery (β = 0.22, p < .01). There was no evidence of an interaction between interpretation bias and mental imagery in predicting HPS score, β = .04, p = .62.Conclusions:Further research is warranted to determine if intrusive imagery or interpretation bias influence the development of bipolar disorder over time in those at risk.

The Self as an Aesthetic Object : Body Image, Beliefs About the Self, and Shame in a Cognitive-Behavioral Model of Body Dysmorphic Disorder

This chapter describes a cognitive-behavioral model of body dysmorphic disorder (BDD), focusing on a core concept of “processing of the self as an aesthetic object.” This concept refers to the experience of being intensely self-focused on a distorted and negative “felt sense” of how one appears to others, and of anticipating or experiencing negative evaluation and rejection because of how one looks. The model proposes that this “felt sense” is informed by intrusive imagery derived from aversive memories, which many individuals with BDD experience. Appearance may become an “idealized value” (i.e., something of primary importance in defining the self and its worth). According to the model, the negative “felt sense” of how the person looks is interpreted in terms of a threat to the self as a whole (e.g., being unacceptable or unlovable). Behavioral responses designed to minimize the threat to the self (e.g., having cosmetic surgery, checking disliked features in the mirror, and avoiding being seen by others) are postulated to instead exaggerate the sense of threat and reinforce the processing of the self as an aesthetic object. Implications for therapeutic intervention are discussed.

“Winter Is Coming!”—Treatment of Obsessive-Compulsive Disorder Imagery After Viewing the Television Series Game of Thrones

This article presents the detailed case of a 27-year-old man who began to suffer from intrusive imagery after watching a brutal scene in the TV series Game of Thrones. The content of the intrusive imagery included images of people with enucleated eyes and was initially accompanied by anxiety about sharp objects. The patient’s mental distress was assessed by the Yale-Brown Obsessive Compulsive Scale and the Impact of Event Scale—Revised, and the patient was diagnosed with obsessive-compulsive disorder (OCD). Eye movement desensitization and reprocessing (EMDR) therapy was provided to treat related distressing memories and the intrusive imagery. As treatment progressed, more complex and layered aspects of the symptom presentation became evident, and EMDR was integrated with other treatments. These included psychodynamic psychotherapy to address his complicated relationship with his father, exposure and response prevention (ERP) therapy to reduce avoidance of sharp objects, and cognitive therapy (CT) for aggressive violent thoughts toward others. The article identifies the various clinical decision points and discusses theoretical conceptualizations and related factors. This clinical case report provides additional support for the body of knowledge on the relationship between traumatic events and imagery in OCD. Therefore, trauma-focused treatments, such as EMDR therapy, which concentrates specifically on those experiences, might be especially effective.

An adapted imaginal exposure approach to traditional methods used within trauma-focused cognitive behavioural therapy, trialled with a veteran population

Trauma-focused cognitive behavioural therapy (TF-CBT) is beneficial for individuals with post-traumatic stress disorder (PTSD); however, a subset of clients struggle to engage with traditional methods, due to high levels of avoidance and dissociation. This paper aims to describe an adapted approach to imaginal reliving and prolonged exposure, to facilitate subsequent cognitive updating. The paper demonstrates the technique with veterans, who are a client group that may struggle with some aspects of traditionally implemented TF-CBT. Two case studies are described, both with PTSD symptoms stemming from traumatic military experiences. An adapted exposure technique is utilized to address the barriers of high dissociation, poor access to trauma-related cognitions and fixed intrusive imagery. The approach involved three stages: (1) reliving the trauma outdoors, (2) manipulating the perspectives of the imagery, and (3) restructuring the narrative with new perspectives. Both clients showed decreased dissociation and improved toleration of their traumatic imagery. Improvement of PTSD symptoms and quality-of-life functioning was observed for both clients on objective measures. Adapting TF-CBT to have a stronger emphasis on grounding and allocentric processing may be helpful for a subset of patients with PTSD that present with high levels of dissociation and avoidance. Further research and investigation into alternative populations is needed.