Emerging Trends in The Social and Behavioral Sciences

Mental Imagery in Psychological Disorders

Item

Title

Mental Imagery in Psychological Disorders

Author

Holmes, Emily A.

Iyadurai, Lalitha

Jacob, Gitta A.

Hales, Susie

Research Area

Psychopathology

Topic

Mental Disorder Varieties

Abstract

Mental imagery involves having an experience like perception but in the absence of a percept. We frequently have mental images such as when we remember an event or imagine the future. In psychological disorders, emotional mental images can flash to mind and be highly distressing, including traumatic memories or simulations of feared future events. However, emotional images have been neglected in research and therapy. This entry combines perspectives from cognitive science (mental imagery) and clinical psychology (psychological disorders). Cognitive science suggests that compared to verbal thoughts, mental imagery has a more powerful impact on emotion. Therefore, it is useful to ask about imagery in clinical assessment of emotional disorders. However, this approach has been largely restricted to PTSD (posttraumatic stress disorder). First, we illustrate that emotional mental imagery occurs across a wide variety of disorders. Second, by mapping the nature of imagery in disorders where it has been neglected (e.g., bipolar disorder), we may be able to import existing imagery therapy techniques (e.g., from PTSD) to improve treatment. Third, by drawing on cognitive science, we can capitalize on the properties inherent to mental imagery to suggest novel techniques. For example, maladaptive imagery may be reduced by cognitive tasks, which interfere with holding an image in mind. Also, adaptive imagery may be boosted by computerized training in generating positive imagery. Intriguingly, this opens the possibility of cognitively informed and computerized psychological treatments that may look rather different from traditional talking therapies.

Related Essays

What Is Neuroticism, and Can We Treat It? (Psychology), Amantia Ametaj et al.

Genetics and the Life Course (Sociology), Evan Charney

Peers and Adolescent Risk Taking (Psychology), Jason Chein

Delusions (Psychology), Max Coltheart

Misinformation and How to Correct It (Psychology), John Cook et al.

Problems Attract Problems: A Network Perspective on Mental Disorders (Psychology), Angélique Cramer and Denny Borsboom

Expertise (Sociology), Gil Eyal

Controlling the Influence of Stereotypes on One's Thoughts (Psychology), Patrick S. Forscher and Patricia G. Devine

Depression (Psychology), Ian H. Gotlib and Daniella J. Furman

Family Relationships and Development (Psychology), Joan E. Grusec

Insomnia and Sleep Disorders (Psychology), Elizabeth C. Mason and Allison G. Harvey

Normal Negative Emotions and Mental Disorders (Sociology), Allan V. Horwitz

Computer Technology and Children's Mental Health (Psychology), Philip C. Kendall et al.

Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology), Shinobu Kitayama and Sarah Huff

Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and Marie‐H. Monfils

Understanding Risk‐Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund

Evolutionary Perspectives on Animal and Human Personality (Anthropology), Joseph H. Manson and Lynn A. Fairbanks

Disorders of Consciousness (Psychology), Martin M. Monti

Social Classification (Sociology), Elizabeth G. Pontikes

Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til Wykes

Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.

Born This Way: Thinking Sociologically about Essentialism (Sociology), Kristen Schilt

Clarifying the Nature and Structure of Personality Disorder (Psychology), Takakuni Suzuki and Douglas B. Samuel

A Gene‐Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.

Rumination (Psychology), Edward R. Watkins

Emotion Regulation (Psychology), Paree Zarolia et al.

Identifier

etrds0216

extracted text

Mental Imagery in Psychological
Disorders
EMILY A. HOLMES, LALITHA IYADURAI, GITTA A. JACOB, and SUSIE HALES

Abstract
Mental imagery involves having an experience like perception but in the absence
of a percept. We frequently have mental images such as when we remember an
event or imagine the future. In psychological disorders, emotional mental images
can flash to mind and be highly distressing, including traumatic memories or simulations of feared future events. However, emotional images have been neglected
in research and therapy. This entry combines perspectives from cognitive science
(mental imagery) and clinical psychology (psychological disorders). Cognitive science suggests that compared to verbal thoughts, mental imagery has a more powerful
impact on emotion. Therefore, it is useful to ask about imagery in clinical assessment
of emotional disorders. However, this approach has been largely restricted to PTSD
(posttraumatic stress disorder). First, we illustrate that emotional mental imagery
occurs across a wide variety of disorders. Second, by mapping the nature of imagery
in disorders where it has been neglected (e.g., bipolar disorder), we may be able to
import existing imagery therapy techniques (e.g., from PTSD) to improve treatment.
Third, by drawing on cognitive science, we can capitalize on the properties inherent
to mental imagery to suggest novel techniques. For example, maladaptive imagery
may be reduced by cognitive tasks, which interfere with holding an image in mind.
Also, adaptive imagery may be boosted by computerized training in generating positive imagery. Intriguingly, this opens the possibility of cognitively informed and
computerized psychological treatments that may look rather different from traditional talking therapies.

INTRODUCTION
Imagine you are reading this and, without warning, you see in your mind’s
eye the worst moment of the most frightening film you have watched. You
see a flash of the movie scene and hear the sounds. You are likely to feel surprised, anxious, and on edge. Now pull away from this mental image and
continue reading. Vivid images capture our imagination and seem to “haunt”
us when they spring to mind. In their most extreme form, emotional mental images cause great distress. Patients with posttraumatic stress disorder
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

2

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

(PTSD) describe recurrent, involuntary image-based memories from a traumatic experience, which bring back strong emotions. Furthermore, we are
discovering that emotional images occur in many other psychological disorders, such as bipolar disorder and depression. While striking to patients,
emotional mental imagery has been relatively neglected in talking therapies
and research alike.
This entry combines perspectives from cognitive science (mental imagery)
and clinical psychology (psychological disorders and their treatment). Experimental psychology studies reveal that compared to verbal thoughts, mental
imagery has a more powerful impact on our emotions (e.g., Holmes, Mathews, Mackintosh, & Dalgleish, 2008). Given that imagery can amplify emotions, we suggest it is useful to ask about imagery in the clinical assessment of
emotional disorders. We will illustrate that emotional mental imagery occurs
across a wide variety of disorders, so is relevant to the broad field of mental
health (Di Simplicio, McInerney, Goodwin, Attenburrow, & Holmes, 2012).
By bridging to cognitive science, we can better understand mechanisms and
may discover novel techniques to work with problematic imagery. Intriguingly, this experimental psychopathology approach opens the possibility of
treatments that look rather different from traditional talking therapies.
BACKGROUND RESEARCH: FROM CLINICAL PSYCHOLOGY
TO COGNITIVE SCIENCE
WHAT IS MENTAL IMAGERY?
When we recall past events or imagine something happening in the future,
we recruit mental imagery. Mental imagery has been described as like having
a sensory experience in the absence of a physical sensory stimulus—“‘seeing
with the mind’s eye,’ ‘hearing with the mind’s ear’ and so on” (Kosslyn,
Ganis, & Thompson, 2001). Although mental imagery is frequently visual,
any of the five senses can be involved. For example, imagine that you are
cutting a lemon—can you feel the skin, smell the zest, see the juice? In
contrast, when we think in verbal thoughts we use words similar to spoken
language, for example, “A squeezed lemon exudes juice”. As we shall see,
such thoughts do not pack the same sort of emotional punch as mental
imagery.
CLINICAL PSYCHOLOGY: EMOTIONAL MENTAL IMAGES OCCUR ACROSS PSYCHOLOGICAL
DISORDERS
In psychological disorders, mental imagery tends to occur involuntarily and
be distressing, with content tied to the theme of the respective disorder. The

Mental Imagery in Psychological Disorders

3

hallmark of PTSD is recurrent and intrusive distressing memories of a traumatic event in the form of emotional images (American Psychiatric Association, 2000). These can be brief images or (rarely) full-blown flashbacks, which
are so intense the patient feels they are “reliving” the event. For example, a
victim of a car accident may have vivid images of car headlights approaching.
In social anxiety disorder—an excessive fear of social situations (American
Psychiatric Association, 2000)—the person may fear acting in an embarrassing way. This belief is maintained by distorted images of how the person sees
himself or herself appearing to others (Hackmann, Clark, & McManus, 2000),
for example, imagining their face as bright red.
We are learning that emotional mental imagery plays a role in a wide
range of disorders (special issues to date: Hackmann & Holmes, 2004, 2012;
Holmes, Arntz, & Smucker, 2007; Krans, 2011; Stopa, 2011). Examples include
snake phobia, suicidality, cravings, health anxiety, obsessive compulsive
disorder, chronic pelvic pain, bipolar disorder, psychosis, body image
disorder, and so on (for reviews, see Brewin, Gregory, Lipton, & Burgess,
2010; Holmes & Mathews, 2010).
COGNITIVE SCIENCE: A SPECIAL RELATIONSHIP BETWEEN MENTAL IMAGERY AND EMOTION
It has long been suggested that mental imagery can influence our emotions.
Lang’s (1979) bio-informational theory proposed that mental images controlled patterns of emotional and behavioral responding. However, only
recently has research directly tested the relative emotional impact of mental
images versus verbal thoughts. In one experiment (Holmes & Mathews,
2005), participants listened to a series of negative scenarios and were either
asked to imagine them, or to think about the words and meanings. The
imagery condition led to a greater increase in anxiety than the verbal condition. This suggests that mental imagery has a more powerful impact on emotion than verbal thought. Consistent with this, those memories that are more
emotional tend to be more image-based (Arntz, de Groot, & Kindt, 2005).
Why might imagery have a more powerful impact on emotion than words?
Mental imagery may rely on the same neural systems as actual perception
(Kosslyn et al., 2001). Furthermore, images induce arousal, similar to that
induced by the actual event. Interestingly, mental images may be more likely
to be confused with real events than verbal descriptions (Mathews, Ridgeway, & Holmes, 2013). Thus, mental imagery may have a similar impact to
directly experiencing something, and in turn make more direct contact with
emotional systems than do words, as illustrated by Holmes and Mathews
(2010); see Figure 1.

4

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Top down
control
processes
Select from

Verbal representation
of emotional meaning

Autobiographic and
semantic memory
knowledge base

(Re) Constructed
image of emotional
instance

Matching

Little overlap with
processing to
perceived events

Contact with
other semantic
knowledge

Bottom up sensory cue

Associates: action
readiness, believability,
attitude to self etc...

Processing overlaps
with perceived events

Direct contact with
emotional systems

Figure 1 The construction of imagery versus verbal representations and their
relative impact on emotion. Source: Taken from Holmes & Mathews, 2010.

CUTTING-EDGE RESEARCH: HOW CAN WE TREAT EMOTIONAL
MENTAL IMAGERY?
CLINICAL PSYCHOLOGY: TECHNIQUES TO TREAT EMOTIONAL MENTAL IMAGERY
Mental imagery has been used in psychological therapies since ancient Egyptian times (Edwards, 2007). Currently, a leading evidence-based form of talking therapy is cognitive behavior therapy (CBT). In CBT, the predominant
focus has been patients’ negative verbal thoughts. Imagery has become a “hot
topic” in the last decade. Imagery techniques, such as those termed exposure and restructuring, are pivotal in CBT for PTSD (Ehlers & Clark, 2000;
Foa, Hembree, & Rothbaum, 2007). CBT for social anxiety disorder has also
been highly successful. The latter tackles social anxiety images using techniques including comparing images with reality via video feedback (Clark
et al., 2006) and “imagery rescripting” in which the problematic imagery is
transformed—akin to reediting a piece of film footage.
The technique of imagery rescripting is now receiving attention for other
disorders (Arntz, 2012). As well as transforming a problematic image,
imagery rescripting can be used to construct new helpful images linked with
more favorable emotions, for example, feeling cared for. Imagery rescripting
is integral to schema therapy—one of the few approaches with an evidence

Mental Imagery in Psychological Disorders

5

base for borderline personality disorder (Arntz & Jacob, 2013). It is also
being applied to other areas such as complex PTSD involving guilt and
anger, to depression (Wheatley et al., 2007), and for feelings of contamination
after childhood sexual abuse (Jung & Steil, 2013).
COGNITIVE SCIENCE: EMERGING TECHNIQUES TO TREAT EMOTIONAL MENTAL IMAGERY
Given the worldwide scale of mental health problems and the limited availability of trained therapists, new treatments that are computerized, simple
to deliver, and readily disseminated may be useful. Therefore, alongside the
development of imagery interventions in talking therapies, recent research
has drawn on cognitive science to propose novel techniques targeting mental
imagery. By bringing in perspectives from cognitive science, we can capitalize on the properties inherent in mental imagery.
For example, from experimental psychology we know that we have limited cognitive resources. If we experience a visual mental image and simultaneously perform a cognitive task requiring visual imagination, the latter
reduces the vividness of the former (Baddeley & Andrade, 2000). This holds
potential for novel techniques to reduce negative emotional mental imagery.
Alternatively, mood-enhancing imagery may be boosted by computerized
training in generating positive imagery. In the next section, we will discuss
two such examples.
FUTURE RESEARCH ON EMOTIONAL MENTAL IMAGERY
There are untapped opportunities to explore emotional mental imagery,
encompassing the fields of both clinical psychology and cognitive psychology. We draw on ideas from our research groups, though clearly many more
are possible and need investigation!
CLINICAL PSYCHOLOGY: MAPPING AND EXTENDING THERAPY TECHNIQUES
Mapping Emotional Imagery in New Domains. We have a grasp of imagery psychopathology in remarkably few areas, though promising work is emerging
across a variety of disorders (Brewin et al., 2010; Holmes & Mathews, 2010).
Extension studies in all aforementioned disorders are warranted; other areas
remain completely unmapped. One direction is the identification of mental
images of imagined events in the future (rather than the past)—termed flashforwards (Engelhard, van den Hout, Janssen, & van der Beek, 2010; Holmes,
Crane, Fennell, & Williams, 2007), or deficits in future imagery such as complicated grief (Robinaugh & McNally, 2013). In many more areas including

6

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

health issues (e.g., pain, cancer), behavioral problems (e.g., smoking, violence), or social concerns (e.g., stigma, prejudice), imagery may play a role.
Research might investigate the phenomenology of any associated imagery
and its role in maintaining the problem.
Not Only Negative, But Problematic “Positive” Imagery. Overly negative mental
imagery is related to pathologically negative emotions. However, overly positive or appetitive imagery can also be problematic, for example, in bipolar
disorder. Bipolar disorder (formerly known as manic depression) is a chronic,
recurrent condition characterized by periods of depression interspersed with
periods of mania (elevated mood). Medication only benefits a modest proportion of patients, and psychological treatments (e.g., CBT) are not yet adequate. How might an imagery perspective help? Mental imagery has been
proposed to act as an “emotional amplifier,” heightening the experience of
mania, depression and anxiety, and destabilizing mood (Holmes, Geddes,
Colom, & Goodwin, 2008). In mania, people strive for goals they may later
regret (Gruber & Johnson, 2009) and take risks (e.g., reckless driving). Consistent with an imagery hypothesis, people with bipolar disorder report a high
general use of mental imagery (Holmes et al., 2011), which may relate to risk
for mania. Future development of more imagery-focused therapy may play
to the strengths of this group, as well as address emotional phenomena not
yet targeted (e.g., overly “positive” flashforwards of future goals).
Imagery Rescripting Techniques: Importing to New Areas and Better Understanding the Mechanisms. By mapping imagery abnormalities in new domains, we
can import existing imagery techniques (e.g., imagery rescripting) to improve
treatments. Imagery rescripting has the potential to reduce a variety of negative emotions including anxiety, shame, and anger in different disorders
(Arntz, 2012). Strikingly, in many clinical areas, imagery techniques have not
yet been tried or have been piloted but not systemically tested. Furthermore,
research on underlying mechanisms is only just starting, and is needed to
develop a scientific understanding of how imagery techniques work.
COGNITIVE SCIENCE: PIONEERING NOVEL AND COMPUTERIZED TECHNIQUES TO TREAT
EMOTIONAL MENTAL IMAGERY
An Example of Translating Experimental Psychology into the Clinic: Preventing the
Build-Up of Flashbacks after Trauma We have good treatments for full-blown
PTSD but lack interventions in the early aftermath of trauma (Roberts,
Kitchiner, Kenardy, & Bisson, 2009). “Flashbacks” (emotional image-based
memories of a traumatic event) are common in the first days and weeks

Mental Imagery in Psychological Disorders

7

posttrauma, although we can only diagnose PTSD at 1 month. Early flashbacks are intrinsically distressing but also predict later PTSD (Creamer,
O’Donnell, & Pattison, 2004). Cognitive science studies have raised the
possibility of reducing the build-up of involuntary negative imagery (i.e.,
flashbacks) by engaging in cognitive tasks soon after traumatic stimuli.
In a series of experiments (Holmes, James, Coode-Bate, & Deeprose, 2009;
Holmes, James, Kilford, & Deeprose, 2010), volunteers watched a film with
traumatic content, and after a break performed either a cognitive task—a
film reminder plus playing the computer game Tetris—or no task as a
control condition. People who played Tetris had fewer flashbacks of the film
over the following week. This has implications for reducing early distress
and preventing PTSD symptoms after trauma. Flashbacks were not reduced
when playing a more verbal computer game—Pub Quiz (Holmes et al.,
2010). Why might playing Tetris reduce flashbacks whereas Pub Quiz did
not? We suggest the following possibility. Tetris is a visuospatial cognitive
task. Concurrent visuospatial tasks reduce the vividness and emotionality
of visual images, for example, trauma film memories (Kavanagh, Freese,
Andrade, & May, 2001; van den Hout, Muris, Salemink, & Kindt, 2001).
There is a time window of a few hours after an event during which memories
are still malleable (Walker, Brakefield, Hobson, & Stickgold, 2003). Playing
Tetris during this window may hinder the consolidation of imagery-based
memories. A more verbal task would not be predicted to have this effect.
Future research needs to consider translation to a clinical setting.
An Example of Boosting Adaptive Imagery: Positive Imagery Training for
Depression. We often focus on the negative thoughts and feelings associated
with depression. However, another important yet neglected angle is the lack
of positive mood and positive imagery. In a depressed mood, it can be hard
to imagine positively either the past (Werner-Seidler & Moulds, 2011) or
future (Morina, Deeprose, Pusowski, Schmid, & Holmes, 2011). Being able
to imagine a positive future has been associated with optimism (Blackwell
et al., 2013). Drawing on the experimental studies showing a stronger impact
of mental imagery on emotion that verbal processing (Holmes, Mathews,
et al., 2008), we have developed ways to train people to use positive imagery.
First studies indicate that computerized training in imaging scenarios that
resolve positively is beneficial for patients with depression (Lang, Blackwell,
Harmer, Davison, & Holmes, 2012). However, larger clinical trials are still
needed. This work could be adjusted for other areas where more adaptive
positive and future imagery is needed.

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Understanding Basic Mechanisms Concerning Emotional Imagery to Fuel Future
Treatments. Mental imagery experiences are on a continuum from our
everyday experiences to clinical disorder. A continuum approach invites
insights about mental imagery from experimental psychology and cognitive
neuroscience to clinical psychology, and vice versa. Examples include
understanding imagery treatments through the lens of more fundamental
mechanisms such as conditioning (Lewis, O-Reilly, Khuu, & Pearson, 2013),
or understanding why some images are intrusive and occur involuntarily
(e.g., Verwoerd, Wessel, & de Jong, 2012). The child development perspective
warrants consideration (Burnett Heyes, Lau, & Holmes, 2013), as in turn will
an aging perspective. Brain imaging techniques may add to our understanding of processes during the encoding (Bourne, Mackay, & Holmes, 2013), construction (Addis, Pan, Vu, Laiser, & Schacter, 2009), perspective (Eich, Nelson,
Leghari, & Handy, 2009), or therapeutic change of emotional imagery. Moreover, we need to develop better experimental measures of emotional imagery
(Pearson, Deeprose, Wallace-Hadrill, Burnett Heyes, & Holmes, 2013).
THE FUTURE: COMBINING COGNITIVE SCIENCE AND CLINICAL PSYCHOLOGY
We have raced our way through an imaginary emotional world of flashbacks and flashforwards, negative and positive imagery, and hope we have
conveyed our fascination with the field. Opportunities to explore emotional
mental imagery reach far beyond those mentioned earlier. Evidence-based
treatment innovations are desperately needed in mental health, and so this
is a “call to arms” for cross-discipline research contributions to this field. We
need to more strongly combine research from clinical psychology and cognitive science perspectives. We need to understand why emotional imagery
has its effects and how to modify it. Approaches pioneered in one area may
be harnessed and applied to new domains. This approach may hold relevance well beyond clinical psychology to health psychology, sports psychology, and social psychology to name a few, connected on a vivid common
thread—the core process of emotional mental imagery.
ACKNOWLEDGMENTS
Cooperation between the authors is supported by the German Research
Foundation (DFG JA1785/4-1) and we are grateful to the Humboldt Foundation for a Friedrich Wilhelm Bessel Research Award to Emily A. Holmes.
Emily Holmes is supported by the Medical Research Council (United Kingdom) intramural programme (MC-A060-5PR50), a grant from the Lupina
Foundation, and a Wellcome Trust Clinical Fellowship (WT088217), and the
National Institute for Health Research (NIHR) Oxford Biomedical Research

Mental Imagery in Psychological Disorders

9

Centre based at Oxford University Hospitals NHS Trust, Oxford University.
The views expressed are those of the author(s) and not necessarily those
of the NHS, the NIHR, or the Department of Health. Lalitha Iyadurai is
supported by a National Institute of Health Research (NIHR) Doctoral
Research Fellowship (NIHR-DRF-2011-04-076). Gitta A. Jacob is supported
by the European Social Fund and the Ministry of Science, Research and
the Arts Baden-Württemberg, and the German Research Foundation (DFG
JA1785/3-1). Susie Hales was supported by the Wellcome Trust (WT088217).

REFERENCES
Addis, D. R., Pan, L., Vu, M., Laiser, N., & Schacter, D. L. (2009). Constructive
episodic simulation of the future and the past: Distinct subsystems of a core brain
network mediate imagining and remembering. Neuropsychologia, 47, 2222–2238.
doi:10.1016/j.neuropsychologica.2008.10.026
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders (4th ed. Text revision). Washington, DC: Author.
Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical
trials, basic studies, and research agenda. Journal of Experimental Psychopathology,
3, 121–126. doi:10.5127/jep.024211
Arntz, A., de Groot, C., & Kindt, M. (2005). Emotional memory is perceptual. Journal
of Behavioural Therapy and Experimental Psychology, 36(1), 19–34.
Arntz, A., & Jacob, G. A. (2013). Schema therapy in practice: An introductory guide to the
schema mode approach. Oxford, England: Wiley-Blackwell.
Baddeley, A. D., & Andrade, J. (2000). Working memory and the vividness of
imagery. Journal of Experimental Psychology-General, 129(1), 126–145.
Blackwell, S. E., Rius-Ottenheim, N., Schulte-van Maaren, Y. W. M., Carlier, I. V. E.,
Middelkoop, V. D., Zitman, F. G., … , Giltay, E. J. (2013). Optimism and mental
imagery: A possible modifiable cognitive marker to promote wellbeing? Psychiatry
Research 206(1), 56-61. doi:10.1016/j.psychres.2012.09.047
Bourne, C., Mackay, C. E., & Holmes, E. A. (2013). The neural basis of flashback formation: The impact of viewing trauma. Psychological Medicine, 43(17), 1521–1533.
doi:10.1017/S0033291712002358
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images
in psychological disorders: Chararcteristics, neural mechanisms, and treatment
implications. Psychological Review, 117(1), 210–232.
Burnett Heyes, S., Lau, J. Y., & Holmes, E. A. (2013). Mental imagery, emotion and
psychopathology across child and adolescent development. Developmental Cognitive Neuroscience, 5, 119–133. doi:10.1016/j.dcn.2013.02.004
Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., … , Wild,
J. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology,
74(3), 568–578.

10

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Creamer, M., O’Donnell, M. L., & Pattison, P. (2004). The relationship between acute
stress disorder and posttraumatic stress disorder in severely injured trauma survivors. Behaviour Research and Therapy, 42, 315–328.
Di Simplicio, M., McInerney, J. E., Goodwin, G. M., Attenburrow, M., & Holmes, E. A.
(2012). Revealing the mind’s eye: Bringing (mental) images into psychiatry. American Journal of Psychiatry, 169(12), 1245–1246. doi:10.1176/appi.ajp.2012.12040499
Edwards, D. (2007). Restructuring implicational meaning through memory-based
imagery: Some historical notes. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 306–316.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder.
Behaviour Research and Therapy, 38(4), 319–345.
Eich, E., Nelson, A. L., Leghari, M. A., & Handy, T. C. (2009). Neural systems mediating field and observer memories. Neuropsychologia, 47(11), 2239–2251.
Engelhard, I. M., van den Hout, M. A., Janssen, W. C., & van der Beek, J. (2010).
Eye movements reduce vividness and emotionality of “flashforwards”. Behaviour
Research and Therapy, 48(5), 442–447.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for
PTSD: Emotional processing of traumatic experiences. New York, NY: Oxford University Press.
Gruber, J., & Johnson, S. L. (2009). Positive emotional traits and ambitious goals
among people at risk for mania: The need for specificity. International Journal of
Cognitive Therapy, 2(2), 176–187.
Hackmann, A., Clark, D. M., & McManus, F. (2000). Recurrent images and early
memories in social phobia. Behaviour Research and Therapy, 38(6), 601–610.
Hackmann, A., & Holmes, E. A. (2004). Reflecting on imagery: A clinical perspective
and overview of the special issue of Memory on mental imagery and memory in
psychopathology. Memory, 12(4), 389–402. doi:10.1080/09658210444000133
Hagenaars, M. A., & Holmes, E. A. (2012). Mental imagery in psychopathology:
Another step; Editorial for the special issue of Journal of Experimental Psychopathology. Journal of Experimental Psychopathology, 3(2), 121–126.
Holmes, E. A., Arntz, A., & Smucker, M. R. (2007). Imagery rescripting in cognitive
behaviour therapy: Images, treatment techniques and outcomes. Journal of Behavior
Therapy and Experimental Psychiatry, 38(4), 297–305. doi:10.1016/j.jbtep.2007.10.007
Holmes, E. A., Crane, C., Fennell, M. J. V., & Williams, J. M. G. (2007). Imagery about
suicide in depression—“Flash-forwards”? Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 423–434. doi:10.1016/j.jbtep.2007.10.004
Holmes, E. A., Deeprose, C., Fairburn, C. G., Wallace-Hadrill, S. M. A., Bonsall, M. B.,
Geddes, J. R., & Goodwin, G. M. (2011). Mood stability versus mood instability in
bipolar disorder: A possible role for emotional mental imagery. Behaviour Research
and Therapy, 49(10), 707–713. doi:10.1016/j.brat.2011.06.008
Holmes, E. A., Geddes, J. R., Colom, F., & Goodwin, G. M. (2008). Mental imagery
as an emotional amplifier: Application to bipolar disorder. Behaviour Research and
Therapy, 46(12), 1251–1258. doi:10.1016/j.brat.2008.09.005
Holmes, E. A., James, E. L., Coode-Bate, T., & Deeprose, C. (2009). Can playing the
computer game “Tetris” reduce the build-Up of flashbacks for trauma? A proposal
from cognitive science. PLoS One, 4(1), e4153. doi:10.1371/journal.pone.0004153

Mental Imagery in Psychological Disorders

11

Holmes, E. A., James, E. L., Kilford, E. J., & Deeprose, C. (2010). Key steps in developing a cognitive vaccine against traumatic flashbacks: visuospatial Tetris versus
verbal Pub Quiz. PLoS One, 5(11), e13706. doi:10.1371/journal.pone.0013706
Holmes, E. A., & Mathews, A. (2005). Mental imagery and emotion: A special relationship? Emotion, 5(4), 489–497. doi:10.1037/1528-3542.5.4.489
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional
disorders. Clinical Psychology Review, 30(3), 349–362. doi:10.1016/j.cpr.2010.01.001
Holmes, E. A., Mathews, A., Mackintosh, B., & Dalgleish, T. (2008). The causal effect
of mental imagery on emotion assessed using picture-word cues. Emotion, 8(3),
395–409. doi:10.1037/1528-3542.8.3.395
Jung, K., & Steil, R. (2013). A randomized controlled trial on cognitive restructuring
and imagery modification to reduce the feeling of being contaminated in adult
survivors of childhood sexual abuse suffering from posttraumatic stress disorder.
Psychotherapy and Psychosomatics, 82(4), 213–220. doi:10.1159/000348450
Kavanagh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks
on desensitization to emotive memories. British Journal of Clinical Psychology, 40(3),
267–280.
Kosslyn, S. M., Ganis, G., & Thompson, W. L. (2001). Neural foundations of imagery.
Nature Reviews Neuroscience, 2(9), 635–642.
Krans, J. (2011). Introduction to the special issue: Intrusive imagery in psychopathology: New research findings, implications for theory and treatment, and future
directions. International Journal of Cognitive Therapy, 4, 117–121.
Lang, P. J. (1979). A bio-informational theory of emotional imagery. Psychophysiology,
16(6), 495–512.
Lang, T. J., Blackwell, S. E., Harmer, C. J., Davison, P., & Holmes, E. A. (2012). Cognitive bias modification using mental imagery for depression: Developing a novel
computerized intervention to change negative thinking styles. European Journal of
Personality, 26(2), 145–157. doi:10.1002/per.855
Lewis, D. E., O-Reilly, M. J., Khuu, S. K., & Pearson, J. (2013). Conditioning the mind’s
eye: Associative learning with voluntary mental imagery. Clinical Psychological Science, 1(4), 390–400. doi:10.1177/2167702613484716
Mathews, A., Ridgeway, V., & Holmes, E. A. (2013). Feels like the real thing: Imagery
is both more realistic and emotional than verbal thought. Cognition & Emotion,
27(2), 217–229. doi:10.1080/02699931.2012.698252
Morina, N., Deeprose, C., Pusowski, C., Schmid, M., & Holmes, E. A. (2011).
Prospective mental imagery in patients with major depressive disorder or anxiety disorders. Journal of Anxiety Disorders, 25(8), 1032–1037. doi:10.1016/j.janxdis.
2011.06.012
Pearson, D. G., Deeprose, C., Wallace-Hadrill, S. M. A., Burnett Heyes, S., & Holmes,
E. A. (2013). Assessing mental imagery in clinical psychology: A review of
imagery measures and a guiding framework. Clinical Psychology Review, 33(1),
1–23. doi:10.1016/j.cpr.2012.09.001
Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bisson, J. I. (2009). Multiple session
early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database of Systematic Reviews Art. No.: CD006869(3). doi:101002/
14651858.CD006869

12

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Robinaugh, D. J., & McNally, R. J. (2013). Remembering the past and envisioning the
future in bereaved adults with and without complicated grief. Clinical Psychological
Science, 1(3), 290–300.
Stopa, L. (2011). Special series: Imagery rescripting across disorders: A practical
guide. Cognitive and Behavioral Practice, 18(4), 421–423.
van den Hout, M. A., Muris, P., Salemink, E., & Kindt, M. (2001). Autobiographical
memories become less vivid and emotional after eye movements. British Journal of
Clinical Psychology, 40(2), 121–130.
Verwoerd, J., Wessel, I., & de Jong, P. J. (2012). Fewer intrusions after an attentional
bias modification training for perceptual reminders of analogue trauma. Cognition
& Emotion, 26(1), 153–165.
Walker, M. P., Brakefield, T., Hobson, J. A., & Stickgold, R. (2003). Dissociable stages
of human memory consolidation and reconsolidation. Nature, 425(6958), 616–620.
Werner-Seidler, A., & Moulds, M. L. (2011). Autobiographical memory characteristics in depression vulnerability: Formerly depressed individuals recall less vivid
positive memories. Cognition & Emotion, 25(6), 1087–1103.
Wheatley, J., Brewin, C. R., Patel, T., Hackmann, A., Wells, A., Fisher, P., & Myers, S.
(2007). “I’ll believe it when I can see it”: Imagery rescripting of intrusive sensory
memories in depression. Journal of Behavior Therapy and Experimental Psychiatry,
38(4), 371–385.

FURTHER READING
Short texts for those in a hurry
Di Simplicio, M., McInerney, J. E., Goodwin, G. M., Attenburrow, M., & Holmes, E. A.
(2012). Revealing the mind’s eye: Bringing (mental) images into psychiatry. American Journal of Psychiatry, 169(12), 1245–1246. doi:10.1176/appi.ajp.2012.12040499
Holmes, E. A., James, E. L., Blackwell, S. E., & Hales, S. (2011). They flash upon that
inward eye. The Psychologist, 24(5), 2–5.
Review papers
Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical
trials, basic studies, and research agenda. Journal of Experimental Psychopathology,
3, 121–126. doi:10.5127/jep.024211
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in
psychological disorders: Characteristics, neural mechanisms, and treatment implications. Psychological Review, 117(1), 210–232.
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional
disorders. Clinical Psychology Review, 30(3), 349–362. doi:10.1016/j.cpr.2010.01.001
Clinical psychology books
Arntz, A., & Jacob, G. (2013). Schema Therapy in Practice: An Introductory Guide to the
Schema Mode Approach. Oxford, England: Wiley-Blackwell.

Mental Imagery in Psychological Disorders

13

Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (2011). Oxford guide to imagery in
cognitive therapy. Oxford, England: Oxford University Press.
First special issue on mental imagery in emotional disorders
Hackmann, A., & Holmes, E. A. (2004). Reflecting on imagery: A clinical perspective
and overview of the special issue of Memory on mental imagery and memory in
psychopathology. Memory, 12(4), 389–402. doi:10.1080/09658210444000133
Imagery and bipolar disorder—an example of imagery as an emotional amplifier
Holmes, E. A., Geddes, J. R., Colom, F., & Goodwin, G. M. (2008). Mental imagery
as an emotional amplifier: Application to bipolar disorder. Behaviour Research and
Therapy, 46(12), 1251–1258. doi:10.1016/j.brat.2008.09.005
Example of how imagery may be used to change beliefs beyond clinical psychology
Birtel, M. D., & Crisp, R. J. (2012). “Treating” prejudice: an exposure-therapy
approach to reducing negative reactions toward stigmatized groups. Psychological
Science, 23(11), 1379–1386. doi:10.1177/0956797612443838

EMILY A. HOLMES SHORT BIOGRAPHY
Emily A. Holmes, PhD, DClinPsych, is a Programme Leader at the MRC
Cognition and Brain Sciences Unit in Cambridge, United Kingdom, and a
Wellcome Trust Clinical Fellow. She is Guest Professor at Karolinksa Institutet, Sweden. Her research places cognitive science alongside clinical psychology, psychiatry, and neuroscience to investigate psychological processes
with a focus on PTSD (posttraumatic stress disorder), depression, and bipolar disorder. Holmes received her degree in Experimental Psychology at the
University of Oxford. She completed her clinical training doctorate at Royal
Holloway University of London, and a PhD in Cognitive Neuroscience at the
MRC Cognition and Brain Sciences Unit. Her overarching interest concerns
mental imagery and emotional disorders.
http://www.mrc-cbu.cam.ac.uk/people/emily.holmes/
LALITHA IYADURAI SHORT BIOGRAPHY
Lalitha Iyadurai, ClinPsyD, is a National Institute for Health Research
(NIHR) Doctoral Research Fellow at the University of Oxford, United
Kingdom. She completed an undergraduate degree in Experimental Psychology at the University of Oxford and a doctorate in Clinical Psychology

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

at the University of Manchester. She is currently working on a DPhil (PhD)
with Holmes in the EPaCT team. The aim is to develop and test a simple
computer task as a preventative intervention to reduce flashbacks after a
road traffic accident.
http://www.psych.ox.ac.uk/team/researchers/lalitha-iyadurai
GITTA JACOB SHORT BIOGRAPHY
Gitta Jacob, PhD, is a research director at GAIA AG in Hamburg and academically affiliated with the Department of Clinical Psychology and Psychotherapy at the University of Freiburg, Germany. She completed her PhD at
the University of Freiburg and her clinical training at the University Medical
Clinic Freiburg. Her clinical work is in the field of adult mental health, with
a focus on borderline personality disorder, schema therapy, and experiential treatment techniques. Her main research foci are emotion regulation and
disinhibition in borderline personality disorder and mechanisms of mental
imagery and imagery rescripting.
http://www.psychologie.uni-freiburg.de/Members/jacob
SUSIE HALES SHORT BIOGRAPHY
Susie Hales, DClinPsych, is a clinical psychologist working with Holmes
in the EPaCT team at the University of Oxford, and in Oxford Health NHS
Foundation Trust. She completed her clinical training doctorate at Oxford
University. Her clinical work is in the field of adult mental health, with a
particular focus on bipolar disorder and imagery. More broadly, she is interested in understanding and evaluating the role of imagery in psychological
disorders and linking this with psychological treatment innovation.
http://www.psych.ox.ac.uk/team/researchers/susie-hales
RELATED ESSAYS
What Is Neuroticism, and Can We Treat It? (Psychology), Amantia Ametaj
et al.
Genetics and the Life Course (Sociology), Evan Charney
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom
Expertise (Sociology), Gil Eyal
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),

Mental Imagery in Psychological Disorders

15

Patrick S. Forscher and Patricia G. Devine
Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Family Relationships and Development (Psychology), Joan E. Grusec
Insomnia and Sleep Disorders (Psychology), Elizabeth C. Mason and Allison
G. Harvey
Normal Negative Emotions and Mental Disorders (Sociology), Allan V.
Horwitz
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Evolutionary Perspectives on Animal and Human Personality (Anthropology), Joseph H. Manson and Lynn A. Fairbanks
Disorders of Consciousness (Psychology), Martin M. Monti
Social Classification (Sociology), Elizabeth G. Pontikes
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.



Mental Imagery in Psychological
Disorders
EMILY A. HOLMES, LALITHA IYADURAI, GITTA A. JACOB, and SUSIE HALES

Abstract
Mental imagery involves having an experience like perception but in the absence
of a percept. We frequently have mental images such as when we remember an
event or imagine the future. In psychological disorders, emotional mental images
can flash to mind and be highly distressing, including traumatic memories or simulations of feared future events. However, emotional images have been neglected
in research and therapy. This entry combines perspectives from cognitive science
(mental imagery) and clinical psychology (psychological disorders). Cognitive science suggests that compared to verbal thoughts, mental imagery has a more powerful
impact on emotion. Therefore, it is useful to ask about imagery in clinical assessment
of emotional disorders. However, this approach has been largely restricted to PTSD
(posttraumatic stress disorder). First, we illustrate that emotional mental imagery
occurs across a wide variety of disorders. Second, by mapping the nature of imagery
in disorders where it has been neglected (e.g., bipolar disorder), we may be able to
import existing imagery therapy techniques (e.g., from PTSD) to improve treatment.
Third, by drawing on cognitive science, we can capitalize on the properties inherent
to mental imagery to suggest novel techniques. For example, maladaptive imagery
may be reduced by cognitive tasks, which interfere with holding an image in mind.
Also, adaptive imagery may be boosted by computerized training in generating positive imagery. Intriguingly, this opens the possibility of cognitively informed and
computerized psychological treatments that may look rather different from traditional talking therapies.

INTRODUCTION
Imagine you are reading this and, without warning, you see in your mind’s
eye the worst moment of the most frightening film you have watched. You
see a flash of the movie scene and hear the sounds. You are likely to feel surprised, anxious, and on edge. Now pull away from this mental image and
continue reading. Vivid images capture our imagination and seem to “haunt”
us when they spring to mind. In their most extreme form, emotional mental images cause great distress. Patients with posttraumatic stress disorder
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

2

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

(PTSD) describe recurrent, involuntary image-based memories from a traumatic experience, which bring back strong emotions. Furthermore, we are
discovering that emotional images occur in many other psychological disorders, such as bipolar disorder and depression. While striking to patients,
emotional mental imagery has been relatively neglected in talking therapies
and research alike.
This entry combines perspectives from cognitive science (mental imagery)
and clinical psychology (psychological disorders and their treatment). Experimental psychology studies reveal that compared to verbal thoughts, mental
imagery has a more powerful impact on our emotions (e.g., Holmes, Mathews, Mackintosh, & Dalgleish, 2008). Given that imagery can amplify emotions, we suggest it is useful to ask about imagery in the clinical assessment of
emotional disorders. We will illustrate that emotional mental imagery occurs
across a wide variety of disorders, so is relevant to the broad field of mental
health (Di Simplicio, McInerney, Goodwin, Attenburrow, & Holmes, 2012).
By bridging to cognitive science, we can better understand mechanisms and
may discover novel techniques to work with problematic imagery. Intriguingly, this experimental psychopathology approach opens the possibility of
treatments that look rather different from traditional talking therapies.
BACKGROUND RESEARCH: FROM CLINICAL PSYCHOLOGY
TO COGNITIVE SCIENCE
WHAT IS MENTAL IMAGERY?
When we recall past events or imagine something happening in the future,
we recruit mental imagery. Mental imagery has been described as like having
a sensory experience in the absence of a physical sensory stimulus—“‘seeing
with the mind’s eye,’ ‘hearing with the mind’s ear’ and so on” (Kosslyn,
Ganis, & Thompson, 2001). Although mental imagery is frequently visual,
any of the five senses can be involved. For example, imagine that you are
cutting a lemon—can you feel the skin, smell the zest, see the juice? In
contrast, when we think in verbal thoughts we use words similar to spoken
language, for example, “A squeezed lemon exudes juice”. As we shall see,
such thoughts do not pack the same sort of emotional punch as mental
imagery.
CLINICAL PSYCHOLOGY: EMOTIONAL MENTAL IMAGES OCCUR ACROSS PSYCHOLOGICAL
DISORDERS
In psychological disorders, mental imagery tends to occur involuntarily and
be distressing, with content tied to the theme of the respective disorder. The

Mental Imagery in Psychological Disorders

3

hallmark of PTSD is recurrent and intrusive distressing memories of a traumatic event in the form of emotional images (American Psychiatric Association, 2000). These can be brief images or (rarely) full-blown flashbacks, which
are so intense the patient feels they are “reliving” the event. For example, a
victim of a car accident may have vivid images of car headlights approaching.
In social anxiety disorder—an excessive fear of social situations (American
Psychiatric Association, 2000)—the person may fear acting in an embarrassing way. This belief is maintained by distorted images of how the person sees
himself or herself appearing to others (Hackmann, Clark, & McManus, 2000),
for example, imagining their face as bright red.
We are learning that emotional mental imagery plays a role in a wide
range of disorders (special issues to date: Hackmann & Holmes, 2004, 2012;
Holmes, Arntz, & Smucker, 2007; Krans, 2011; Stopa, 2011). Examples include
snake phobia, suicidality, cravings, health anxiety, obsessive compulsive
disorder, chronic pelvic pain, bipolar disorder, psychosis, body image
disorder, and so on (for reviews, see Brewin, Gregory, Lipton, & Burgess,
2010; Holmes & Mathews, 2010).
COGNITIVE SCIENCE: A SPECIAL RELATIONSHIP BETWEEN MENTAL IMAGERY AND EMOTION
It has long been suggested that mental imagery can influence our emotions.
Lang’s (1979) bio-informational theory proposed that mental images controlled patterns of emotional and behavioral responding. However, only
recently has research directly tested the relative emotional impact of mental
images versus verbal thoughts. In one experiment (Holmes & Mathews,
2005), participants listened to a series of negative scenarios and were either
asked to imagine them, or to think about the words and meanings. The
imagery condition led to a greater increase in anxiety than the verbal condition. This suggests that mental imagery has a more powerful impact on emotion than verbal thought. Consistent with this, those memories that are more
emotional tend to be more image-based (Arntz, de Groot, & Kindt, 2005).
Why might imagery have a more powerful impact on emotion than words?
Mental imagery may rely on the same neural systems as actual perception
(Kosslyn et al., 2001). Furthermore, images induce arousal, similar to that
induced by the actual event. Interestingly, mental images may be more likely
to be confused with real events than verbal descriptions (Mathews, Ridgeway, & Holmes, 2013). Thus, mental imagery may have a similar impact to
directly experiencing something, and in turn make more direct contact with
emotional systems than do words, as illustrated by Holmes and Mathews
(2010); see Figure 1.

4

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Top down
control
processes
Select from

Verbal representation
of emotional meaning

Autobiographic and
semantic memory
knowledge base

(Re) Constructed
image of emotional
instance

Matching

Little overlap with
processing to
perceived events

Contact with
other semantic
knowledge

Bottom up sensory cue

Associates: action
readiness, believability,
attitude to self etc...

Processing overlaps
with perceived events

Direct contact with
emotional systems

Figure 1 The construction of imagery versus verbal representations and their
relative impact on emotion. Source: Taken from Holmes & Mathews, 2010.

CUTTING-EDGE RESEARCH: HOW CAN WE TREAT EMOTIONAL
MENTAL IMAGERY?
CLINICAL PSYCHOLOGY: TECHNIQUES TO TREAT EMOTIONAL MENTAL IMAGERY
Mental imagery has been used in psychological therapies since ancient Egyptian times (Edwards, 2007). Currently, a leading evidence-based form of talking therapy is cognitive behavior therapy (CBT). In CBT, the predominant
focus has been patients’ negative verbal thoughts. Imagery has become a “hot
topic” in the last decade. Imagery techniques, such as those termed exposure and restructuring, are pivotal in CBT for PTSD (Ehlers & Clark, 2000;
Foa, Hembree, & Rothbaum, 2007). CBT for social anxiety disorder has also
been highly successful. The latter tackles social anxiety images using techniques including comparing images with reality via video feedback (Clark
et al., 2006) and “imagery rescripting” in which the problematic imagery is
transformed—akin to reediting a piece of film footage.
The technique of imagery rescripting is now receiving attention for other
disorders (Arntz, 2012). As well as transforming a problematic image,
imagery rescripting can be used to construct new helpful images linked with
more favorable emotions, for example, feeling cared for. Imagery rescripting
is integral to schema therapy—one of the few approaches with an evidence

Mental Imagery in Psychological Disorders

5

base for borderline personality disorder (Arntz & Jacob, 2013). It is also
being applied to other areas such as complex PTSD involving guilt and
anger, to depression (Wheatley et al., 2007), and for feelings of contamination
after childhood sexual abuse (Jung & Steil, 2013).
COGNITIVE SCIENCE: EMERGING TECHNIQUES TO TREAT EMOTIONAL MENTAL IMAGERY
Given the worldwide scale of mental health problems and the limited availability of trained therapists, new treatments that are computerized, simple
to deliver, and readily disseminated may be useful. Therefore, alongside the
development of imagery interventions in talking therapies, recent research
has drawn on cognitive science to propose novel techniques targeting mental
imagery. By bringing in perspectives from cognitive science, we can capitalize on the properties inherent in mental imagery.
For example, from experimental psychology we know that we have limited cognitive resources. If we experience a visual mental image and simultaneously perform a cognitive task requiring visual imagination, the latter
reduces the vividness of the former (Baddeley & Andrade, 2000). This holds
potential for novel techniques to reduce negative emotional mental imagery.
Alternatively, mood-enhancing imagery may be boosted by computerized
training in generating positive imagery. In the next section, we will discuss
two such examples.
FUTURE RESEARCH ON EMOTIONAL MENTAL IMAGERY
There are untapped opportunities to explore emotional mental imagery,
encompassing the fields of both clinical psychology and cognitive psychology. We draw on ideas from our research groups, though clearly many more
are possible and need investigation!
CLINICAL PSYCHOLOGY: MAPPING AND EXTENDING THERAPY TECHNIQUES
Mapping Emotional Imagery in New Domains. We have a grasp of imagery psychopathology in remarkably few areas, though promising work is emerging
across a variety of disorders (Brewin et al., 2010; Holmes & Mathews, 2010).
Extension studies in all aforementioned disorders are warranted; other areas
remain completely unmapped. One direction is the identification of mental
images of imagined events in the future (rather than the past)—termed flashforwards (Engelhard, van den Hout, Janssen, & van der Beek, 2010; Holmes,
Crane, Fennell, & Williams, 2007), or deficits in future imagery such as complicated grief (Robinaugh & McNally, 2013). In many more areas including

6

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

health issues (e.g., pain, cancer), behavioral problems (e.g., smoking, violence), or social concerns (e.g., stigma, prejudice), imagery may play a role.
Research might investigate the phenomenology of any associated imagery
and its role in maintaining the problem.
Not Only Negative, But Problematic “Positive” Imagery. Overly negative mental
imagery is related to pathologically negative emotions. However, overly positive or appetitive imagery can also be problematic, for example, in bipolar
disorder. Bipolar disorder (formerly known as manic depression) is a chronic,
recurrent condition characterized by periods of depression interspersed with
periods of mania (elevated mood). Medication only benefits a modest proportion of patients, and psychological treatments (e.g., CBT) are not yet adequate. How might an imagery perspective help? Mental imagery has been
proposed to act as an “emotional amplifier,” heightening the experience of
mania, depression and anxiety, and destabilizing mood (Holmes, Geddes,
Colom, & Goodwin, 2008). In mania, people strive for goals they may later
regret (Gruber & Johnson, 2009) and take risks (e.g., reckless driving). Consistent with an imagery hypothesis, people with bipolar disorder report a high
general use of mental imagery (Holmes et al., 2011), which may relate to risk
for mania. Future development of more imagery-focused therapy may play
to the strengths of this group, as well as address emotional phenomena not
yet targeted (e.g., overly “positive” flashforwards of future goals).
Imagery Rescripting Techniques: Importing to New Areas and Better Understanding the Mechanisms. By mapping imagery abnormalities in new domains, we
can import existing imagery techniques (e.g., imagery rescripting) to improve
treatments. Imagery rescripting has the potential to reduce a variety of negative emotions including anxiety, shame, and anger in different disorders
(Arntz, 2012). Strikingly, in many clinical areas, imagery techniques have not
yet been tried or have been piloted but not systemically tested. Furthermore,
research on underlying mechanisms is only just starting, and is needed to
develop a scientific understanding of how imagery techniques work.
COGNITIVE SCIENCE: PIONEERING NOVEL AND COMPUTERIZED TECHNIQUES TO TREAT
EMOTIONAL MENTAL IMAGERY
An Example of Translating Experimental Psychology into the Clinic: Preventing the
Build-Up of Flashbacks after Trauma We have good treatments for full-blown
PTSD but lack interventions in the early aftermath of trauma (Roberts,
Kitchiner, Kenardy, & Bisson, 2009). “Flashbacks” (emotional image-based
memories of a traumatic event) are common in the first days and weeks

Mental Imagery in Psychological Disorders

7

posttrauma, although we can only diagnose PTSD at 1 month. Early flashbacks are intrinsically distressing but also predict later PTSD (Creamer,
O’Donnell, & Pattison, 2004). Cognitive science studies have raised the
possibility of reducing the build-up of involuntary negative imagery (i.e.,
flashbacks) by engaging in cognitive tasks soon after traumatic stimuli.
In a series of experiments (Holmes, James, Coode-Bate, & Deeprose, 2009;
Holmes, James, Kilford, & Deeprose, 2010), volunteers watched a film with
traumatic content, and after a break performed either a cognitive task—a
film reminder plus playing the computer game Tetris—or no task as a
control condition. People who played Tetris had fewer flashbacks of the film
over the following week. This has implications for reducing early distress
and preventing PTSD symptoms after trauma. Flashbacks were not reduced
when playing a more verbal computer game—Pub Quiz (Holmes et al.,
2010). Why might playing Tetris reduce flashbacks whereas Pub Quiz did
not? We suggest the following possibility. Tetris is a visuospatial cognitive
task. Concurrent visuospatial tasks reduce the vividness and emotionality
of visual images, for example, trauma film memories (Kavanagh, Freese,
Andrade, & May, 2001; van den Hout, Muris, Salemink, & Kindt, 2001).
There is a time window of a few hours after an event during which memories
are still malleable (Walker, Brakefield, Hobson, & Stickgold, 2003). Playing
Tetris during this window may hinder the consolidation of imagery-based
memories. A more verbal task would not be predicted to have this effect.
Future research needs to consider translation to a clinical setting.
An Example of Boosting Adaptive Imagery: Positive Imagery Training for
Depression. We often focus on the negative thoughts and feelings associated
with depression. However, another important yet neglected angle is the lack
of positive mood and positive imagery. In a depressed mood, it can be hard
to imagine positively either the past (Werner-Seidler & Moulds, 2011) or
future (Morina, Deeprose, Pusowski, Schmid, & Holmes, 2011). Being able
to imagine a positive future has been associated with optimism (Blackwell
et al., 2013). Drawing on the experimental studies showing a stronger impact
of mental imagery on emotion that verbal processing (Holmes, Mathews,
et al., 2008), we have developed ways to train people to use positive imagery.
First studies indicate that computerized training in imaging scenarios that
resolve positively is beneficial for patients with depression (Lang, Blackwell,
Harmer, Davison, & Holmes, 2012). However, larger clinical trials are still
needed. This work could be adjusted for other areas where more adaptive
positive and future imagery is needed.

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Understanding Basic Mechanisms Concerning Emotional Imagery to Fuel Future
Treatments. Mental imagery experiences are on a continuum from our
everyday experiences to clinical disorder. A continuum approach invites
insights about mental imagery from experimental psychology and cognitive
neuroscience to clinical psychology, and vice versa. Examples include
understanding imagery treatments through the lens of more fundamental
mechanisms such as conditioning (Lewis, O-Reilly, Khuu, & Pearson, 2013),
or understanding why some images are intrusive and occur involuntarily
(e.g., Verwoerd, Wessel, & de Jong, 2012). The child development perspective
warrants consideration (Burnett Heyes, Lau, & Holmes, 2013), as in turn will
an aging perspective. Brain imaging techniques may add to our understanding of processes during the encoding (Bourne, Mackay, & Holmes, 2013), construction (Addis, Pan, Vu, Laiser, & Schacter, 2009), perspective (Eich, Nelson,
Leghari, & Handy, 2009), or therapeutic change of emotional imagery. Moreover, we need to develop better experimental measures of emotional imagery
(Pearson, Deeprose, Wallace-Hadrill, Burnett Heyes, & Holmes, 2013).
THE FUTURE: COMBINING COGNITIVE SCIENCE AND CLINICAL PSYCHOLOGY
We have raced our way through an imaginary emotional world of flashbacks and flashforwards, negative and positive imagery, and hope we have
conveyed our fascination with the field. Opportunities to explore emotional
mental imagery reach far beyond those mentioned earlier. Evidence-based
treatment innovations are desperately needed in mental health, and so this
is a “call to arms” for cross-discipline research contributions to this field. We
need to more strongly combine research from clinical psychology and cognitive science perspectives. We need to understand why emotional imagery
has its effects and how to modify it. Approaches pioneered in one area may
be harnessed and applied to new domains. This approach may hold relevance well beyond clinical psychology to health psychology, sports psychology, and social psychology to name a few, connected on a vivid common
thread—the core process of emotional mental imagery.
ACKNOWLEDGMENTS
Cooperation between the authors is supported by the German Research
Foundation (DFG JA1785/4-1) and we are grateful to the Humboldt Foundation for a Friedrich Wilhelm Bessel Research Award to Emily A. Holmes.
Emily Holmes is supported by the Medical Research Council (United Kingdom) intramural programme (MC-A060-5PR50), a grant from the Lupina
Foundation, and a Wellcome Trust Clinical Fellowship (WT088217), and the
National Institute for Health Research (NIHR) Oxford Biomedical Research

Mental Imagery in Psychological Disorders

9

Centre based at Oxford University Hospitals NHS Trust, Oxford University.
The views expressed are those of the author(s) and not necessarily those
of the NHS, the NIHR, or the Department of Health. Lalitha Iyadurai is
supported by a National Institute of Health Research (NIHR) Doctoral
Research Fellowship (NIHR-DRF-2011-04-076). Gitta A. Jacob is supported
by the European Social Fund and the Ministry of Science, Research and
the Arts Baden-Württemberg, and the German Research Foundation (DFG
JA1785/3-1). Susie Hales was supported by the Wellcome Trust (WT088217).

REFERENCES
Addis, D. R., Pan, L., Vu, M., Laiser, N., & Schacter, D. L. (2009). Constructive
episodic simulation of the future and the past: Distinct subsystems of a core brain
network mediate imagining and remembering. Neuropsychologia, 47, 2222–2238.
doi:10.1016/j.neuropsychologica.2008.10.026
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders (4th ed. Text revision). Washington, DC: Author.
Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical
trials, basic studies, and research agenda. Journal of Experimental Psychopathology,
3, 121–126. doi:10.5127/jep.024211
Arntz, A., de Groot, C., & Kindt, M. (2005). Emotional memory is perceptual. Journal
of Behavioural Therapy and Experimental Psychology, 36(1), 19–34.
Arntz, A., & Jacob, G. A. (2013). Schema therapy in practice: An introductory guide to the
schema mode approach. Oxford, England: Wiley-Blackwell.
Baddeley, A. D., & Andrade, J. (2000). Working memory and the vividness of
imagery. Journal of Experimental Psychology-General, 129(1), 126–145.
Blackwell, S. E., Rius-Ottenheim, N., Schulte-van Maaren, Y. W. M., Carlier, I. V. E.,
Middelkoop, V. D., Zitman, F. G., … , Giltay, E. J. (2013). Optimism and mental
imagery: A possible modifiable cognitive marker to promote wellbeing? Psychiatry
Research 206(1), 56-61. doi:10.1016/j.psychres.2012.09.047
Bourne, C., Mackay, C. E., & Holmes, E. A. (2013). The neural basis of flashback formation: The impact of viewing trauma. Psychological Medicine, 43(17), 1521–1533.
doi:10.1017/S0033291712002358
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images
in psychological disorders: Chararcteristics, neural mechanisms, and treatment
implications. Psychological Review, 117(1), 210–232.
Burnett Heyes, S., Lau, J. Y., & Holmes, E. A. (2013). Mental imagery, emotion and
psychopathology across child and adolescent development. Developmental Cognitive Neuroscience, 5, 119–133. doi:10.1016/j.dcn.2013.02.004
Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., … , Wild,
J. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology,
74(3), 568–578.

10

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Creamer, M., O’Donnell, M. L., & Pattison, P. (2004). The relationship between acute
stress disorder and posttraumatic stress disorder in severely injured trauma survivors. Behaviour Research and Therapy, 42, 315–328.
Di Simplicio, M., McInerney, J. E., Goodwin, G. M., Attenburrow, M., & Holmes, E. A.
(2012). Revealing the mind’s eye: Bringing (mental) images into psychiatry. American Journal of Psychiatry, 169(12), 1245–1246. doi:10.1176/appi.ajp.2012.12040499
Edwards, D. (2007). Restructuring implicational meaning through memory-based
imagery: Some historical notes. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 306–316.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder.
Behaviour Research and Therapy, 38(4), 319–345.
Eich, E., Nelson, A. L., Leghari, M. A., & Handy, T. C. (2009). Neural systems mediating field and observer memories. Neuropsychologia, 47(11), 2239–2251.
Engelhard, I. M., van den Hout, M. A., Janssen, W. C., & van der Beek, J. (2010).
Eye movements reduce vividness and emotionality of “flashforwards”. Behaviour
Research and Therapy, 48(5), 442–447.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for
PTSD: Emotional processing of traumatic experiences. New York, NY: Oxford University Press.
Gruber, J., & Johnson, S. L. (2009). Positive emotional traits and ambitious goals
among people at risk for mania: The need for specificity. International Journal of
Cognitive Therapy, 2(2), 176–187.
Hackmann, A., Clark, D. M., & McManus, F. (2000). Recurrent images and early
memories in social phobia. Behaviour Research and Therapy, 38(6), 601–610.
Hackmann, A., & Holmes, E. A. (2004). Reflecting on imagery: A clinical perspective
and overview of the special issue of Memory on mental imagery and memory in
psychopathology. Memory, 12(4), 389–402. doi:10.1080/09658210444000133
Hagenaars, M. A., & Holmes, E. A. (2012). Mental imagery in psychopathology:
Another step; Editorial for the special issue of Journal of Experimental Psychopathology. Journal of Experimental Psychopathology, 3(2), 121–126.
Holmes, E. A., Arntz, A., & Smucker, M. R. (2007). Imagery rescripting in cognitive
behaviour therapy: Images, treatment techniques and outcomes. Journal of Behavior
Therapy and Experimental Psychiatry, 38(4), 297–305. doi:10.1016/j.jbtep.2007.10.007
Holmes, E. A., Crane, C., Fennell, M. J. V., & Williams, J. M. G. (2007). Imagery about
suicide in depression—“Flash-forwards”? Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 423–434. doi:10.1016/j.jbtep.2007.10.004
Holmes, E. A., Deeprose, C., Fairburn, C. G., Wallace-Hadrill, S. M. A., Bonsall, M. B.,
Geddes, J. R., & Goodwin, G. M. (2011). Mood stability versus mood instability in
bipolar disorder: A possible role for emotional mental imagery. Behaviour Research
and Therapy, 49(10), 707–713. doi:10.1016/j.brat.2011.06.008
Holmes, E. A., Geddes, J. R., Colom, F., & Goodwin, G. M. (2008). Mental imagery
as an emotional amplifier: Application to bipolar disorder. Behaviour Research and
Therapy, 46(12), 1251–1258. doi:10.1016/j.brat.2008.09.005
Holmes, E. A., James, E. L., Coode-Bate, T., & Deeprose, C. (2009). Can playing the
computer game “Tetris” reduce the build-Up of flashbacks for trauma? A proposal
from cognitive science. PLoS One, 4(1), e4153. doi:10.1371/journal.pone.0004153

Mental Imagery in Psychological Disorders

11

Holmes, E. A., James, E. L., Kilford, E. J., & Deeprose, C. (2010). Key steps in developing a cognitive vaccine against traumatic flashbacks: visuospatial Tetris versus
verbal Pub Quiz. PLoS One, 5(11), e13706. doi:10.1371/journal.pone.0013706
Holmes, E. A., & Mathews, A. (2005). Mental imagery and emotion: A special relationship? Emotion, 5(4), 489–497. doi:10.1037/1528-3542.5.4.489
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional
disorders. Clinical Psychology Review, 30(3), 349–362. doi:10.1016/j.cpr.2010.01.001
Holmes, E. A., Mathews, A., Mackintosh, B., & Dalgleish, T. (2008). The causal effect
of mental imagery on emotion assessed using picture-word cues. Emotion, 8(3),
395–409. doi:10.1037/1528-3542.8.3.395
Jung, K., & Steil, R. (2013). A randomized controlled trial on cognitive restructuring
and imagery modification to reduce the feeling of being contaminated in adult
survivors of childhood sexual abuse suffering from posttraumatic stress disorder.
Psychotherapy and Psychosomatics, 82(4), 213–220. doi:10.1159/000348450
Kavanagh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks
on desensitization to emotive memories. British Journal of Clinical Psychology, 40(3),
267–280.
Kosslyn, S. M., Ganis, G., & Thompson, W. L. (2001). Neural foundations of imagery.
Nature Reviews Neuroscience, 2(9), 635–642.
Krans, J. (2011). Introduction to the special issue: Intrusive imagery in psychopathology: New research findings, implications for theory and treatment, and future
directions. International Journal of Cognitive Therapy, 4, 117–121.
Lang, P. J. (1979). A bio-informational theory of emotional imagery. Psychophysiology,
16(6), 495–512.
Lang, T. J., Blackwell, S. E., Harmer, C. J., Davison, P., & Holmes, E. A. (2012). Cognitive bias modification using mental imagery for depression: Developing a novel
computerized intervention to change negative thinking styles. European Journal of
Personality, 26(2), 145–157. doi:10.1002/per.855
Lewis, D. E., O-Reilly, M. J., Khuu, S. K., & Pearson, J. (2013). Conditioning the mind’s
eye: Associative learning with voluntary mental imagery. Clinical Psychological Science, 1(4), 390–400. doi:10.1177/2167702613484716
Mathews, A., Ridgeway, V., & Holmes, E. A. (2013). Feels like the real thing: Imagery
is both more realistic and emotional than verbal thought. Cognition & Emotion,
27(2), 217–229. doi:10.1080/02699931.2012.698252
Morina, N., Deeprose, C., Pusowski, C., Schmid, M., & Holmes, E. A. (2011).
Prospective mental imagery in patients with major depressive disorder or anxiety disorders. Journal of Anxiety Disorders, 25(8), 1032–1037. doi:10.1016/j.janxdis.
2011.06.012
Pearson, D. G., Deeprose, C., Wallace-Hadrill, S. M. A., Burnett Heyes, S., & Holmes,
E. A. (2013). Assessing mental imagery in clinical psychology: A review of
imagery measures and a guiding framework. Clinical Psychology Review, 33(1),
1–23. doi:10.1016/j.cpr.2012.09.001
Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bisson, J. I. (2009). Multiple session
early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database of Systematic Reviews Art. No.: CD006869(3). doi:101002/
14651858.CD006869

12

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Robinaugh, D. J., & McNally, R. J. (2013). Remembering the past and envisioning the
future in bereaved adults with and without complicated grief. Clinical Psychological
Science, 1(3), 290–300.
Stopa, L. (2011). Special series: Imagery rescripting across disorders: A practical
guide. Cognitive and Behavioral Practice, 18(4), 421–423.
van den Hout, M. A., Muris, P., Salemink, E., & Kindt, M. (2001). Autobiographical
memories become less vivid and emotional after eye movements. British Journal of
Clinical Psychology, 40(2), 121–130.
Verwoerd, J., Wessel, I., & de Jong, P. J. (2012). Fewer intrusions after an attentional
bias modification training for perceptual reminders of analogue trauma. Cognition
& Emotion, 26(1), 153–165.
Walker, M. P., Brakefield, T., Hobson, J. A., & Stickgold, R. (2003). Dissociable stages
of human memory consolidation and reconsolidation. Nature, 425(6958), 616–620.
Werner-Seidler, A., & Moulds, M. L. (2011). Autobiographical memory characteristics in depression vulnerability: Formerly depressed individuals recall less vivid
positive memories. Cognition & Emotion, 25(6), 1087–1103.
Wheatley, J., Brewin, C. R., Patel, T., Hackmann, A., Wells, A., Fisher, P., & Myers, S.
(2007). “I’ll believe it when I can see it”: Imagery rescripting of intrusive sensory
memories in depression. Journal of Behavior Therapy and Experimental Psychiatry,
38(4), 371–385.

FURTHER READING
Short texts for those in a hurry
Di Simplicio, M., McInerney, J. E., Goodwin, G. M., Attenburrow, M., & Holmes, E. A.
(2012). Revealing the mind’s eye: Bringing (mental) images into psychiatry. American Journal of Psychiatry, 169(12), 1245–1246. doi:10.1176/appi.ajp.2012.12040499
Holmes, E. A., James, E. L., Blackwell, S. E., & Hales, S. (2011). They flash upon that
inward eye. The Psychologist, 24(5), 2–5.
Review papers
Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical
trials, basic studies, and research agenda. Journal of Experimental Psychopathology,
3, 121–126. doi:10.5127/jep.024211
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in
psychological disorders: Characteristics, neural mechanisms, and treatment implications. Psychological Review, 117(1), 210–232.
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional
disorders. Clinical Psychology Review, 30(3), 349–362. doi:10.1016/j.cpr.2010.01.001
Clinical psychology books
Arntz, A., & Jacob, G. (2013). Schema Therapy in Practice: An Introductory Guide to the
Schema Mode Approach. Oxford, England: Wiley-Blackwell.

Mental Imagery in Psychological Disorders

13

Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (2011). Oxford guide to imagery in
cognitive therapy. Oxford, England: Oxford University Press.
First special issue on mental imagery in emotional disorders
Hackmann, A., & Holmes, E. A. (2004). Reflecting on imagery: A clinical perspective
and overview of the special issue of Memory on mental imagery and memory in
psychopathology. Memory, 12(4), 389–402. doi:10.1080/09658210444000133
Imagery and bipolar disorder—an example of imagery as an emotional amplifier
Holmes, E. A., Geddes, J. R., Colom, F., & Goodwin, G. M. (2008). Mental imagery
as an emotional amplifier: Application to bipolar disorder. Behaviour Research and
Therapy, 46(12), 1251–1258. doi:10.1016/j.brat.2008.09.005
Example of how imagery may be used to change beliefs beyond clinical psychology
Birtel, M. D., & Crisp, R. J. (2012). “Treating” prejudice: an exposure-therapy
approach to reducing negative reactions toward stigmatized groups. Psychological
Science, 23(11), 1379–1386. doi:10.1177/0956797612443838

EMILY A. HOLMES SHORT BIOGRAPHY
Emily A. Holmes, PhD, DClinPsych, is a Programme Leader at the MRC
Cognition and Brain Sciences Unit in Cambridge, United Kingdom, and a
Wellcome Trust Clinical Fellow. She is Guest Professor at Karolinksa Institutet, Sweden. Her research places cognitive science alongside clinical psychology, psychiatry, and neuroscience to investigate psychological processes
with a focus on PTSD (posttraumatic stress disorder), depression, and bipolar disorder. Holmes received her degree in Experimental Psychology at the
University of Oxford. She completed her clinical training doctorate at Royal
Holloway University of London, and a PhD in Cognitive Neuroscience at the
MRC Cognition and Brain Sciences Unit. Her overarching interest concerns
mental imagery and emotional disorders.
http://www.mrc-cbu.cam.ac.uk/people/emily.holmes/
LALITHA IYADURAI SHORT BIOGRAPHY
Lalitha Iyadurai, ClinPsyD, is a National Institute for Health Research
(NIHR) Doctoral Research Fellow at the University of Oxford, United
Kingdom. She completed an undergraduate degree in Experimental Psychology at the University of Oxford and a doctorate in Clinical Psychology

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

at the University of Manchester. She is currently working on a DPhil (PhD)
with Holmes in the EPaCT team. The aim is to develop and test a simple
computer task as a preventative intervention to reduce flashbacks after a
road traffic accident.
http://www.psych.ox.ac.uk/team/researchers/lalitha-iyadurai
GITTA JACOB SHORT BIOGRAPHY
Gitta Jacob, PhD, is a research director at GAIA AG in Hamburg and academically affiliated with the Department of Clinical Psychology and Psychotherapy at the University of Freiburg, Germany. She completed her PhD at
the University of Freiburg and her clinical training at the University Medical
Clinic Freiburg. Her clinical work is in the field of adult mental health, with
a focus on borderline personality disorder, schema therapy, and experiential treatment techniques. Her main research foci are emotion regulation and
disinhibition in borderline personality disorder and mechanisms of mental
imagery and imagery rescripting.
http://www.psychologie.uni-freiburg.de/Members/jacob
SUSIE HALES SHORT BIOGRAPHY
Susie Hales, DClinPsych, is a clinical psychologist working with Holmes
in the EPaCT team at the University of Oxford, and in Oxford Health NHS
Foundation Trust. She completed her clinical training doctorate at Oxford
University. Her clinical work is in the field of adult mental health, with a
particular focus on bipolar disorder and imagery. More broadly, she is interested in understanding and evaluating the role of imagery in psychological
disorders and linking this with psychological treatment innovation.
http://www.psych.ox.ac.uk/team/researchers/susie-hales
RELATED ESSAYS
What Is Neuroticism, and Can We Treat It? (Psychology), Amantia Ametaj
et al.
Genetics and the Life Course (Sociology), Evan Charney
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom
Expertise (Sociology), Gil Eyal
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),

Mental Imagery in Psychological Disorders

15

Patrick S. Forscher and Patricia G. Devine
Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Family Relationships and Development (Psychology), Joan E. Grusec
Insomnia and Sleep Disorders (Psychology), Elizabeth C. Mason and Allison
G. Harvey
Normal Negative Emotions and Mental Disorders (Sociology), Allan V.
Horwitz
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Evolutionary Perspectives on Animal and Human Personality (Anthropology), Joseph H. Manson and Lynn A. Fairbanks
Disorders of Consciousness (Psychology), Martin M. Monti
Social Classification (Sociology), Elizabeth G. Pontikes
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.


Mental Imagery in Psychological
Disorders
EMILY A. HOLMES, LALITHA IYADURAI, GITTA A. JACOB, and SUSIE HALES

Abstract
Mental imagery involves having an experience like perception but in the absence
of a percept. We frequently have mental images such as when we remember an
event or imagine the future. In psychological disorders, emotional mental images
can flash to mind and be highly distressing, including traumatic memories or simulations of feared future events. However, emotional images have been neglected
in research and therapy. This entry combines perspectives from cognitive science
(mental imagery) and clinical psychology (psychological disorders). Cognitive science suggests that compared to verbal thoughts, mental imagery has a more powerful
impact on emotion. Therefore, it is useful to ask about imagery in clinical assessment
of emotional disorders. However, this approach has been largely restricted to PTSD
(posttraumatic stress disorder). First, we illustrate that emotional mental imagery
occurs across a wide variety of disorders. Second, by mapping the nature of imagery
in disorders where it has been neglected (e.g., bipolar disorder), we may be able to
import existing imagery therapy techniques (e.g., from PTSD) to improve treatment.
Third, by drawing on cognitive science, we can capitalize on the properties inherent
to mental imagery to suggest novel techniques. For example, maladaptive imagery
may be reduced by cognitive tasks, which interfere with holding an image in mind.
Also, adaptive imagery may be boosted by computerized training in generating positive imagery. Intriguingly, this opens the possibility of cognitively informed and
computerized psychological treatments that may look rather different from traditional talking therapies.

INTRODUCTION
Imagine you are reading this and, without warning, you see in your mind’s
eye the worst moment of the most frightening film you have watched. You
see a flash of the movie scene and hear the sounds. You are likely to feel surprised, anxious, and on edge. Now pull away from this mental image and
continue reading. Vivid images capture our imagination and seem to “haunt”
us when they spring to mind. In their most extreme form, emotional mental images cause great distress. Patients with posttraumatic stress disorder
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

2

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

(PTSD) describe recurrent, involuntary image-based memories from a traumatic experience, which bring back strong emotions. Furthermore, we are
discovering that emotional images occur in many other psychological disorders, such as bipolar disorder and depression. While striking to patients,
emotional mental imagery has been relatively neglected in talking therapies
and research alike.
This entry combines perspectives from cognitive science (mental imagery)
and clinical psychology (psychological disorders and their treatment). Experimental psychology studies reveal that compared to verbal thoughts, mental
imagery has a more powerful impact on our emotions (e.g., Holmes, Mathews, Mackintosh, & Dalgleish, 2008). Given that imagery can amplify emotions, we suggest it is useful to ask about imagery in the clinical assessment of
emotional disorders. We will illustrate that emotional mental imagery occurs
across a wide variety of disorders, so is relevant to the broad field of mental
health (Di Simplicio, McInerney, Goodwin, Attenburrow, & Holmes, 2012).
By bridging to cognitive science, we can better understand mechanisms and
may discover novel techniques to work with problematic imagery. Intriguingly, this experimental psychopathology approach opens the possibility of
treatments that look rather different from traditional talking therapies.
BACKGROUND RESEARCH: FROM CLINICAL PSYCHOLOGY
TO COGNITIVE SCIENCE
WHAT IS MENTAL IMAGERY?
When we recall past events or imagine something happening in the future,
we recruit mental imagery. Mental imagery has been described as like having
a sensory experience in the absence of a physical sensory stimulus—“‘seeing
with the mind’s eye,’ ‘hearing with the mind’s ear’ and so on” (Kosslyn,
Ganis, & Thompson, 2001). Although mental imagery is frequently visual,
any of the five senses can be involved. For example, imagine that you are
cutting a lemon—can you feel the skin, smell the zest, see the juice? In
contrast, when we think in verbal thoughts we use words similar to spoken
language, for example, “A squeezed lemon exudes juice”. As we shall see,
such thoughts do not pack the same sort of emotional punch as mental
imagery.
CLINICAL PSYCHOLOGY: EMOTIONAL MENTAL IMAGES OCCUR ACROSS PSYCHOLOGICAL
DISORDERS
In psychological disorders, mental imagery tends to occur involuntarily and
be distressing, with content tied to the theme of the respective disorder. The

Mental Imagery in Psychological Disorders

3

hallmark of PTSD is recurrent and intrusive distressing memories of a traumatic event in the form of emotional images (American Psychiatric Association, 2000). These can be brief images or (rarely) full-blown flashbacks, which
are so intense the patient feels they are “reliving” the event. For example, a
victim of a car accident may have vivid images of car headlights approaching.
In social anxiety disorder—an excessive fear of social situations (American
Psychiatric Association, 2000)—the person may fear acting in an embarrassing way. This belief is maintained by distorted images of how the person sees
himself or herself appearing to others (Hackmann, Clark, & McManus, 2000),
for example, imagining their face as bright red.
We are learning that emotional mental imagery plays a role in a wide
range of disorders (special issues to date: Hackmann & Holmes, 2004, 2012;
Holmes, Arntz, & Smucker, 2007; Krans, 2011; Stopa, 2011). Examples include
snake phobia, suicidality, cravings, health anxiety, obsessive compulsive
disorder, chronic pelvic pain, bipolar disorder, psychosis, body image
disorder, and so on (for reviews, see Brewin, Gregory, Lipton, & Burgess,
2010; Holmes & Mathews, 2010).
COGNITIVE SCIENCE: A SPECIAL RELATIONSHIP BETWEEN MENTAL IMAGERY AND EMOTION
It has long been suggested that mental imagery can influence our emotions.
Lang’s (1979) bio-informational theory proposed that mental images controlled patterns of emotional and behavioral responding. However, only
recently has research directly tested the relative emotional impact of mental
images versus verbal thoughts. In one experiment (Holmes & Mathews,
2005), participants listened to a series of negative scenarios and were either
asked to imagine them, or to think about the words and meanings. The
imagery condition led to a greater increase in anxiety than the verbal condition. This suggests that mental imagery has a more powerful impact on emotion than verbal thought. Consistent with this, those memories that are more
emotional tend to be more image-based (Arntz, de Groot, & Kindt, 2005).
Why might imagery have a more powerful impact on emotion than words?
Mental imagery may rely on the same neural systems as actual perception
(Kosslyn et al., 2001). Furthermore, images induce arousal, similar to that
induced by the actual event. Interestingly, mental images may be more likely
to be confused with real events than verbal descriptions (Mathews, Ridgeway, & Holmes, 2013). Thus, mental imagery may have a similar impact to
directly experiencing something, and in turn make more direct contact with
emotional systems than do words, as illustrated by Holmes and Mathews
(2010); see Figure 1.

4

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Top down
control
processes
Select from

Verbal representation
of emotional meaning

Autobiographic and
semantic memory
knowledge base

(Re) Constructed
image of emotional
instance

Matching

Little overlap with
processing to
perceived events

Contact with
other semantic
knowledge

Bottom up sensory cue

Associates: action
readiness, believability,
attitude to self etc...

Processing overlaps
with perceived events

Direct contact with
emotional systems

Figure 1 The construction of imagery versus verbal representations and their
relative impact on emotion. Source: Taken from Holmes & Mathews, 2010.

CUTTING-EDGE RESEARCH: HOW CAN WE TREAT EMOTIONAL
MENTAL IMAGERY?
CLINICAL PSYCHOLOGY: TECHNIQUES TO TREAT EMOTIONAL MENTAL IMAGERY
Mental imagery has been used in psychological therapies since ancient Egyptian times (Edwards, 2007). Currently, a leading evidence-based form of talking therapy is cognitive behavior therapy (CBT). In CBT, the predominant
focus has been patients’ negative verbal thoughts. Imagery has become a “hot
topic” in the last decade. Imagery techniques, such as those termed exposure and restructuring, are pivotal in CBT for PTSD (Ehlers & Clark, 2000;
Foa, Hembree, & Rothbaum, 2007). CBT for social anxiety disorder has also
been highly successful. The latter tackles social anxiety images using techniques including comparing images with reality via video feedback (Clark
et al., 2006) and “imagery rescripting” in which the problematic imagery is
transformed—akin to reediting a piece of film footage.
The technique of imagery rescripting is now receiving attention for other
disorders (Arntz, 2012). As well as transforming a problematic image,
imagery rescripting can be used to construct new helpful images linked with
more favorable emotions, for example, feeling cared for. Imagery rescripting
is integral to schema therapy—one of the few approaches with an evidence

Mental Imagery in Psychological Disorders

5

base for borderline personality disorder (Arntz & Jacob, 2013). It is also
being applied to other areas such as complex PTSD involving guilt and
anger, to depression (Wheatley et al., 2007), and for feelings of contamination
after childhood sexual abuse (Jung & Steil, 2013).
COGNITIVE SCIENCE: EMERGING TECHNIQUES TO TREAT EMOTIONAL MENTAL IMAGERY
Given the worldwide scale of mental health problems and the limited availability of trained therapists, new treatments that are computerized, simple
to deliver, and readily disseminated may be useful. Therefore, alongside the
development of imagery interventions in talking therapies, recent research
has drawn on cognitive science to propose novel techniques targeting mental
imagery. By bringing in perspectives from cognitive science, we can capitalize on the properties inherent in mental imagery.
For example, from experimental psychology we know that we have limited cognitive resources. If we experience a visual mental image and simultaneously perform a cognitive task requiring visual imagination, the latter
reduces the vividness of the former (Baddeley & Andrade, 2000). This holds
potential for novel techniques to reduce negative emotional mental imagery.
Alternatively, mood-enhancing imagery may be boosted by computerized
training in generating positive imagery. In the next section, we will discuss
two such examples.
FUTURE RESEARCH ON EMOTIONAL MENTAL IMAGERY
There are untapped opportunities to explore emotional mental imagery,
encompassing the fields of both clinical psychology and cognitive psychology. We draw on ideas from our research groups, though clearly many more
are possible and need investigation!
CLINICAL PSYCHOLOGY: MAPPING AND EXTENDING THERAPY TECHNIQUES
Mapping Emotional Imagery in New Domains. We have a grasp of imagery psychopathology in remarkably few areas, though promising work is emerging
across a variety of disorders (Brewin et al., 2010; Holmes & Mathews, 2010).
Extension studies in all aforementioned disorders are warranted; other areas
remain completely unmapped. One direction is the identification of mental
images of imagined events in the future (rather than the past)—termed flashforwards (Engelhard, van den Hout, Janssen, & van der Beek, 2010; Holmes,
Crane, Fennell, & Williams, 2007), or deficits in future imagery such as complicated grief (Robinaugh & McNally, 2013). In many more areas including

6

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

health issues (e.g., pain, cancer), behavioral problems (e.g., smoking, violence), or social concerns (e.g., stigma, prejudice), imagery may play a role.
Research might investigate the phenomenology of any associated imagery
and its role in maintaining the problem.
Not Only Negative, But Problematic “Positive” Imagery. Overly negative mental
imagery is related to pathologically negative emotions. However, overly positive or appetitive imagery can also be problematic, for example, in bipolar
disorder. Bipolar disorder (formerly known as manic depression) is a chronic,
recurrent condition characterized by periods of depression interspersed with
periods of mania (elevated mood). Medication only benefits a modest proportion of patients, and psychological treatments (e.g., CBT) are not yet adequate. How might an imagery perspective help? Mental imagery has been
proposed to act as an “emotional amplifier,” heightening the experience of
mania, depression and anxiety, and destabilizing mood (Holmes, Geddes,
Colom, & Goodwin, 2008). In mania, people strive for goals they may later
regret (Gruber & Johnson, 2009) and take risks (e.g., reckless driving). Consistent with an imagery hypothesis, people with bipolar disorder report a high
general use of mental imagery (Holmes et al., 2011), which may relate to risk
for mania. Future development of more imagery-focused therapy may play
to the strengths of this group, as well as address emotional phenomena not
yet targeted (e.g., overly “positive” flashforwards of future goals).
Imagery Rescripting Techniques: Importing to New Areas and Better Understanding the Mechanisms. By mapping imagery abnormalities in new domains, we
can import existing imagery techniques (e.g., imagery rescripting) to improve
treatments. Imagery rescripting has the potential to reduce a variety of negative emotions including anxiety, shame, and anger in different disorders
(Arntz, 2012). Strikingly, in many clinical areas, imagery techniques have not
yet been tried or have been piloted but not systemically tested. Furthermore,
research on underlying mechanisms is only just starting, and is needed to
develop a scientific understanding of how imagery techniques work.
COGNITIVE SCIENCE: PIONEERING NOVEL AND COMPUTERIZED TECHNIQUES TO TREAT
EMOTIONAL MENTAL IMAGERY
An Example of Translating Experimental Psychology into the Clinic: Preventing the
Build-Up of Flashbacks after Trauma We have good treatments for full-blown
PTSD but lack interventions in the early aftermath of trauma (Roberts,
Kitchiner, Kenardy, & Bisson, 2009). “Flashbacks” (emotional image-based
memories of a traumatic event) are common in the first days and weeks

Mental Imagery in Psychological Disorders

7

posttrauma, although we can only diagnose PTSD at 1 month. Early flashbacks are intrinsically distressing but also predict later PTSD (Creamer,
O’Donnell, & Pattison, 2004). Cognitive science studies have raised the
possibility of reducing the build-up of involuntary negative imagery (i.e.,
flashbacks) by engaging in cognitive tasks soon after traumatic stimuli.
In a series of experiments (Holmes, James, Coode-Bate, & Deeprose, 2009;
Holmes, James, Kilford, & Deeprose, 2010), volunteers watched a film with
traumatic content, and after a break performed either a cognitive task—a
film reminder plus playing the computer game Tetris—or no task as a
control condition. People who played Tetris had fewer flashbacks of the film
over the following week. This has implications for reducing early distress
and preventing PTSD symptoms after trauma. Flashbacks were not reduced
when playing a more verbal computer game—Pub Quiz (Holmes et al.,
2010). Why might playing Tetris reduce flashbacks whereas Pub Quiz did
not? We suggest the following possibility. Tetris is a visuospatial cognitive
task. Concurrent visuospatial tasks reduce the vividness and emotionality
of visual images, for example, trauma film memories (Kavanagh, Freese,
Andrade, & May, 2001; van den Hout, Muris, Salemink, & Kindt, 2001).
There is a time window of a few hours after an event during which memories
are still malleable (Walker, Brakefield, Hobson, & Stickgold, 2003). Playing
Tetris during this window may hinder the consolidation of imagery-based
memories. A more verbal task would not be predicted to have this effect.
Future research needs to consider translation to a clinical setting.
An Example of Boosting Adaptive Imagery: Positive Imagery Training for
Depression. We often focus on the negative thoughts and feelings associated
with depression. However, another important yet neglected angle is the lack
of positive mood and positive imagery. In a depressed mood, it can be hard
to imagine positively either the past (Werner-Seidler & Moulds, 2011) or
future (Morina, Deeprose, Pusowski, Schmid, & Holmes, 2011). Being able
to imagine a positive future has been associated with optimism (Blackwell
et al., 2013). Drawing on the experimental studies showing a stronger impact
of mental imagery on emotion that verbal processing (Holmes, Mathews,
et al., 2008), we have developed ways to train people to use positive imagery.
First studies indicate that computerized training in imaging scenarios that
resolve positively is beneficial for patients with depression (Lang, Blackwell,
Harmer, Davison, & Holmes, 2012). However, larger clinical trials are still
needed. This work could be adjusted for other areas where more adaptive
positive and future imagery is needed.

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Understanding Basic Mechanisms Concerning Emotional Imagery to Fuel Future
Treatments. Mental imagery experiences are on a continuum from our
everyday experiences to clinical disorder. A continuum approach invites
insights about mental imagery from experimental psychology and cognitive
neuroscience to clinical psychology, and vice versa. Examples include
understanding imagery treatments through the lens of more fundamental
mechanisms such as conditioning (Lewis, O-Reilly, Khuu, & Pearson, 2013),
or understanding why some images are intrusive and occur involuntarily
(e.g., Verwoerd, Wessel, & de Jong, 2012). The child development perspective
warrants consideration (Burnett Heyes, Lau, & Holmes, 2013), as in turn will
an aging perspective. Brain imaging techniques may add to our understanding of processes during the encoding (Bourne, Mackay, & Holmes, 2013), construction (Addis, Pan, Vu, Laiser, & Schacter, 2009), perspective (Eich, Nelson,
Leghari, & Handy, 2009), or therapeutic change of emotional imagery. Moreover, we need to develop better experimental measures of emotional imagery
(Pearson, Deeprose, Wallace-Hadrill, Burnett Heyes, & Holmes, 2013).
THE FUTURE: COMBINING COGNITIVE SCIENCE AND CLINICAL PSYCHOLOGY
We have raced our way through an imaginary emotional world of flashbacks and flashforwards, negative and positive imagery, and hope we have
conveyed our fascination with the field. Opportunities to explore emotional
mental imagery reach far beyond those mentioned earlier. Evidence-based
treatment innovations are desperately needed in mental health, and so this
is a “call to arms” for cross-discipline research contributions to this field. We
need to more strongly combine research from clinical psychology and cognitive science perspectives. We need to understand why emotional imagery
has its effects and how to modify it. Approaches pioneered in one area may
be harnessed and applied to new domains. This approach may hold relevance well beyond clinical psychology to health psychology, sports psychology, and social psychology to name a few, connected on a vivid common
thread—the core process of emotional mental imagery.
ACKNOWLEDGMENTS
Cooperation between the authors is supported by the German Research
Foundation (DFG JA1785/4-1) and we are grateful to the Humboldt Foundation for a Friedrich Wilhelm Bessel Research Award to Emily A. Holmes.
Emily Holmes is supported by the Medical Research Council (United Kingdom) intramural programme (MC-A060-5PR50), a grant from the Lupina
Foundation, and a Wellcome Trust Clinical Fellowship (WT088217), and the
National Institute for Health Research (NIHR) Oxford Biomedical Research

Mental Imagery in Psychological Disorders

9

Centre based at Oxford University Hospitals NHS Trust, Oxford University.
The views expressed are those of the author(s) and not necessarily those
of the NHS, the NIHR, or the Department of Health. Lalitha Iyadurai is
supported by a National Institute of Health Research (NIHR) Doctoral
Research Fellowship (NIHR-DRF-2011-04-076). Gitta A. Jacob is supported
by the European Social Fund and the Ministry of Science, Research and
the Arts Baden-Württemberg, and the German Research Foundation (DFG
JA1785/3-1). Susie Hales was supported by the Wellcome Trust (WT088217).

REFERENCES
Addis, D. R., Pan, L., Vu, M., Laiser, N., & Schacter, D. L. (2009). Constructive
episodic simulation of the future and the past: Distinct subsystems of a core brain
network mediate imagining and remembering. Neuropsychologia, 47, 2222–2238.
doi:10.1016/j.neuropsychologica.2008.10.026
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders (4th ed. Text revision). Washington, DC: Author.
Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical
trials, basic studies, and research agenda. Journal of Experimental Psychopathology,
3, 121–126. doi:10.5127/jep.024211
Arntz, A., de Groot, C., & Kindt, M. (2005). Emotional memory is perceptual. Journal
of Behavioural Therapy and Experimental Psychology, 36(1), 19–34.
Arntz, A., & Jacob, G. A. (2013). Schema therapy in practice: An introductory guide to the
schema mode approach. Oxford, England: Wiley-Blackwell.
Baddeley, A. D., & Andrade, J. (2000). Working memory and the vividness of
imagery. Journal of Experimental Psychology-General, 129(1), 126–145.
Blackwell, S. E., Rius-Ottenheim, N., Schulte-van Maaren, Y. W. M., Carlier, I. V. E.,
Middelkoop, V. D., Zitman, F. G., … , Giltay, E. J. (2013). Optimism and mental
imagery: A possible modifiable cognitive marker to promote wellbeing? Psychiatry
Research 206(1), 56-61. doi:10.1016/j.psychres.2012.09.047
Bourne, C., Mackay, C. E., & Holmes, E. A. (2013). The neural basis of flashback formation: The impact of viewing trauma. Psychological Medicine, 43(17), 1521–1533.
doi:10.1017/S0033291712002358
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images
in psychological disorders: Chararcteristics, neural mechanisms, and treatment
implications. Psychological Review, 117(1), 210–232.
Burnett Heyes, S., Lau, J. Y., & Holmes, E. A. (2013). Mental imagery, emotion and
psychopathology across child and adolescent development. Developmental Cognitive Neuroscience, 5, 119–133. doi:10.1016/j.dcn.2013.02.004
Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., … , Wild,
J. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology,
74(3), 568–578.

10

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Creamer, M., O’Donnell, M. L., & Pattison, P. (2004). The relationship between acute
stress disorder and posttraumatic stress disorder in severely injured trauma survivors. Behaviour Research and Therapy, 42, 315–328.
Di Simplicio, M., McInerney, J. E., Goodwin, G. M., Attenburrow, M., & Holmes, E. A.
(2012). Revealing the mind’s eye: Bringing (mental) images into psychiatry. American Journal of Psychiatry, 169(12), 1245–1246. doi:10.1176/appi.ajp.2012.12040499
Edwards, D. (2007). Restructuring implicational meaning through memory-based
imagery: Some historical notes. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 306–316.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder.
Behaviour Research and Therapy, 38(4), 319–345.
Eich, E., Nelson, A. L., Leghari, M. A., & Handy, T. C. (2009). Neural systems mediating field and observer memories. Neuropsychologia, 47(11), 2239–2251.
Engelhard, I. M., van den Hout, M. A., Janssen, W. C., & van der Beek, J. (2010).
Eye movements reduce vividness and emotionality of “flashforwards”. Behaviour
Research and Therapy, 48(5), 442–447.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for
PTSD: Emotional processing of traumatic experiences. New York, NY: Oxford University Press.
Gruber, J., & Johnson, S. L. (2009). Positive emotional traits and ambitious goals
among people at risk for mania: The need for specificity. International Journal of
Cognitive Therapy, 2(2), 176–187.
Hackmann, A., Clark, D. M., & McManus, F. (2000). Recurrent images and early
memories in social phobia. Behaviour Research and Therapy, 38(6), 601–610.
Hackmann, A., & Holmes, E. A. (2004). Reflecting on imagery: A clinical perspective
and overview of the special issue of Memory on mental imagery and memory in
psychopathology. Memory, 12(4), 389–402. doi:10.1080/09658210444000133
Hagenaars, M. A., & Holmes, E. A. (2012). Mental imagery in psychopathology:
Another step; Editorial for the special issue of Journal of Experimental Psychopathology. Journal of Experimental Psychopathology, 3(2), 121–126.
Holmes, E. A., Arntz, A., & Smucker, M. R. (2007). Imagery rescripting in cognitive
behaviour therapy: Images, treatment techniques and outcomes. Journal of Behavior
Therapy and Experimental Psychiatry, 38(4), 297–305. doi:10.1016/j.jbtep.2007.10.007
Holmes, E. A., Crane, C., Fennell, M. J. V., & Williams, J. M. G. (2007). Imagery about
suicide in depression—“Flash-forwards”? Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 423–434. doi:10.1016/j.jbtep.2007.10.004
Holmes, E. A., Deeprose, C., Fairburn, C. G., Wallace-Hadrill, S. M. A., Bonsall, M. B.,
Geddes, J. R., & Goodwin, G. M. (2011). Mood stability versus mood instability in
bipolar disorder: A possible role for emotional mental imagery. Behaviour Research
and Therapy, 49(10), 707–713. doi:10.1016/j.brat.2011.06.008
Holmes, E. A., Geddes, J. R., Colom, F., & Goodwin, G. M. (2008). Mental imagery
as an emotional amplifier: Application to bipolar disorder. Behaviour Research and
Therapy, 46(12), 1251–1258. doi:10.1016/j.brat.2008.09.005
Holmes, E. A., James, E. L., Coode-Bate, T., & Deeprose, C. (2009). Can playing the
computer game “Tetris” reduce the build-Up of flashbacks for trauma? A proposal
from cognitive science. PLoS One, 4(1), e4153. doi:10.1371/journal.pone.0004153

Mental Imagery in Psychological Disorders

11

Holmes, E. A., James, E. L., Kilford, E. J., & Deeprose, C. (2010). Key steps in developing a cognitive vaccine against traumatic flashbacks: visuospatial Tetris versus
verbal Pub Quiz. PLoS One, 5(11), e13706. doi:10.1371/journal.pone.0013706
Holmes, E. A., & Mathews, A. (2005). Mental imagery and emotion: A special relationship? Emotion, 5(4), 489–497. doi:10.1037/1528-3542.5.4.489
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional
disorders. Clinical Psychology Review, 30(3), 349–362. doi:10.1016/j.cpr.2010.01.001
Holmes, E. A., Mathews, A., Mackintosh, B., & Dalgleish, T. (2008). The causal effect
of mental imagery on emotion assessed using picture-word cues. Emotion, 8(3),
395–409. doi:10.1037/1528-3542.8.3.395
Jung, K., & Steil, R. (2013). A randomized controlled trial on cognitive restructuring
and imagery modification to reduce the feeling of being contaminated in adult
survivors of childhood sexual abuse suffering from posttraumatic stress disorder.
Psychotherapy and Psychosomatics, 82(4), 213–220. doi:10.1159/000348450
Kavanagh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks
on desensitization to emotive memories. British Journal of Clinical Psychology, 40(3),
267–280.
Kosslyn, S. M., Ganis, G., & Thompson, W. L. (2001). Neural foundations of imagery.
Nature Reviews Neuroscience, 2(9), 635–642.
Krans, J. (2011). Introduction to the special issue: Intrusive imagery in psychopathology: New research findings, implications for theory and treatment, and future
directions. International Journal of Cognitive Therapy, 4, 117–121.
Lang, P. J. (1979). A bio-informational theory of emotional imagery. Psychophysiology,
16(6), 495–512.
Lang, T. J., Blackwell, S. E., Harmer, C. J., Davison, P., & Holmes, E. A. (2012). Cognitive bias modification using mental imagery for depression: Developing a novel
computerized intervention to change negative thinking styles. European Journal of
Personality, 26(2), 145–157. doi:10.1002/per.855
Lewis, D. E., O-Reilly, M. J., Khuu, S. K., & Pearson, J. (2013). Conditioning the mind’s
eye: Associative learning with voluntary mental imagery. Clinical Psychological Science, 1(4), 390–400. doi:10.1177/2167702613484716
Mathews, A., Ridgeway, V., & Holmes, E. A. (2013). Feels like the real thing: Imagery
is both more realistic and emotional than verbal thought. Cognition & Emotion,
27(2), 217–229. doi:10.1080/02699931.2012.698252
Morina, N., Deeprose, C., Pusowski, C., Schmid, M., & Holmes, E. A. (2011).
Prospective mental imagery in patients with major depressive disorder or anxiety disorders. Journal of Anxiety Disorders, 25(8), 1032–1037. doi:10.1016/j.janxdis.
2011.06.012
Pearson, D. G., Deeprose, C., Wallace-Hadrill, S. M. A., Burnett Heyes, S., & Holmes,
E. A. (2013). Assessing mental imagery in clinical psychology: A review of
imagery measures and a guiding framework. Clinical Psychology Review, 33(1),
1–23. doi:10.1016/j.cpr.2012.09.001
Roberts, N. P., Kitchiner, N. J., Kenardy, J., & Bisson, J. I. (2009). Multiple session
early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database of Systematic Reviews Art. No.: CD006869(3). doi:101002/
14651858.CD006869

12

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Robinaugh, D. J., & McNally, R. J. (2013). Remembering the past and envisioning the
future in bereaved adults with and without complicated grief. Clinical Psychological
Science, 1(3), 290–300.
Stopa, L. (2011). Special series: Imagery rescripting across disorders: A practical
guide. Cognitive and Behavioral Practice, 18(4), 421–423.
van den Hout, M. A., Muris, P., Salemink, E., & Kindt, M. (2001). Autobiographical
memories become less vivid and emotional after eye movements. British Journal of
Clinical Psychology, 40(2), 121–130.
Verwoerd, J., Wessel, I., & de Jong, P. J. (2012). Fewer intrusions after an attentional
bias modification training for perceptual reminders of analogue trauma. Cognition
& Emotion, 26(1), 153–165.
Walker, M. P., Brakefield, T., Hobson, J. A., & Stickgold, R. (2003). Dissociable stages
of human memory consolidation and reconsolidation. Nature, 425(6958), 616–620.
Werner-Seidler, A., & Moulds, M. L. (2011). Autobiographical memory characteristics in depression vulnerability: Formerly depressed individuals recall less vivid
positive memories. Cognition & Emotion, 25(6), 1087–1103.
Wheatley, J., Brewin, C. R., Patel, T., Hackmann, A., Wells, A., Fisher, P., & Myers, S.
(2007). “I’ll believe it when I can see it”: Imagery rescripting of intrusive sensory
memories in depression. Journal of Behavior Therapy and Experimental Psychiatry,
38(4), 371–385.

FURTHER READING
Short texts for those in a hurry
Di Simplicio, M., McInerney, J. E., Goodwin, G. M., Attenburrow, M., & Holmes, E. A.
(2012). Revealing the mind’s eye: Bringing (mental) images into psychiatry. American Journal of Psychiatry, 169(12), 1245–1246. doi:10.1176/appi.ajp.2012.12040499
Holmes, E. A., James, E. L., Blackwell, S. E., & Hales, S. (2011). They flash upon that
inward eye. The Psychologist, 24(5), 2–5.
Review papers
Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical
trials, basic studies, and research agenda. Journal of Experimental Psychopathology,
3, 121–126. doi:10.5127/jep.024211
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in
psychological disorders: Characteristics, neural mechanisms, and treatment implications. Psychological Review, 117(1), 210–232.
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional
disorders. Clinical Psychology Review, 30(3), 349–362. doi:10.1016/j.cpr.2010.01.001
Clinical psychology books
Arntz, A., & Jacob, G. (2013). Schema Therapy in Practice: An Introductory Guide to the
Schema Mode Approach. Oxford, England: Wiley-Blackwell.

Mental Imagery in Psychological Disorders

13

Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (2011). Oxford guide to imagery in
cognitive therapy. Oxford, England: Oxford University Press.
First special issue on mental imagery in emotional disorders
Hackmann, A., & Holmes, E. A. (2004). Reflecting on imagery: A clinical perspective
and overview of the special issue of Memory on mental imagery and memory in
psychopathology. Memory, 12(4), 389–402. doi:10.1080/09658210444000133
Imagery and bipolar disorder—an example of imagery as an emotional amplifier
Holmes, E. A., Geddes, J. R., Colom, F., & Goodwin, G. M. (2008). Mental imagery
as an emotional amplifier: Application to bipolar disorder. Behaviour Research and
Therapy, 46(12), 1251–1258. doi:10.1016/j.brat.2008.09.005
Example of how imagery may be used to change beliefs beyond clinical psychology
Birtel, M. D., & Crisp, R. J. (2012). “Treating” prejudice: an exposure-therapy
approach to reducing negative reactions toward stigmatized groups. Psychological
Science, 23(11), 1379–1386. doi:10.1177/0956797612443838

EMILY A. HOLMES SHORT BIOGRAPHY
Emily A. Holmes, PhD, DClinPsych, is a Programme Leader at the MRC
Cognition and Brain Sciences Unit in Cambridge, United Kingdom, and a
Wellcome Trust Clinical Fellow. She is Guest Professor at Karolinksa Institutet, Sweden. Her research places cognitive science alongside clinical psychology, psychiatry, and neuroscience to investigate psychological processes
with a focus on PTSD (posttraumatic stress disorder), depression, and bipolar disorder. Holmes received her degree in Experimental Psychology at the
University of Oxford. She completed her clinical training doctorate at Royal
Holloway University of London, and a PhD in Cognitive Neuroscience at the
MRC Cognition and Brain Sciences Unit. Her overarching interest concerns
mental imagery and emotional disorders.
http://www.mrc-cbu.cam.ac.uk/people/emily.holmes/
LALITHA IYADURAI SHORT BIOGRAPHY
Lalitha Iyadurai, ClinPsyD, is a National Institute for Health Research
(NIHR) Doctoral Research Fellow at the University of Oxford, United
Kingdom. She completed an undergraduate degree in Experimental Psychology at the University of Oxford and a doctorate in Clinical Psychology

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

at the University of Manchester. She is currently working on a DPhil (PhD)
with Holmes in the EPaCT team. The aim is to develop and test a simple
computer task as a preventative intervention to reduce flashbacks after a
road traffic accident.
http://www.psych.ox.ac.uk/team/researchers/lalitha-iyadurai
GITTA JACOB SHORT BIOGRAPHY
Gitta Jacob, PhD, is a research director at GAIA AG in Hamburg and academically affiliated with the Department of Clinical Psychology and Psychotherapy at the University of Freiburg, Germany. She completed her PhD at
the University of Freiburg and her clinical training at the University Medical
Clinic Freiburg. Her clinical work is in the field of adult mental health, with
a focus on borderline personality disorder, schema therapy, and experiential treatment techniques. Her main research foci are emotion regulation and
disinhibition in borderline personality disorder and mechanisms of mental
imagery and imagery rescripting.
http://www.psychologie.uni-freiburg.de/Members/jacob
SUSIE HALES SHORT BIOGRAPHY
Susie Hales, DClinPsych, is a clinical psychologist working with Holmes
in the EPaCT team at the University of Oxford, and in Oxford Health NHS
Foundation Trust. She completed her clinical training doctorate at Oxford
University. Her clinical work is in the field of adult mental health, with a
particular focus on bipolar disorder and imagery. More broadly, she is interested in understanding and evaluating the role of imagery in psychological
disorders and linking this with psychological treatment innovation.
http://www.psych.ox.ac.uk/team/researchers/susie-hales
RELATED ESSAYS
What Is Neuroticism, and Can We Treat It? (Psychology), Amantia Ametaj
et al.
Genetics and the Life Course (Sociology), Evan Charney
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom
Expertise (Sociology), Gil Eyal
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),

Mental Imagery in Psychological Disorders

15

Patrick S. Forscher and Patricia G. Devine
Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Family Relationships and Development (Psychology), Joan E. Grusec
Insomnia and Sleep Disorders (Psychology), Elizabeth C. Mason and Allison
G. Harvey
Normal Negative Emotions and Mental Disorders (Sociology), Allan V.
Horwitz
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Evolutionary Perspectives on Animal and Human Personality (Anthropology), Joseph H. Manson and Lynn A. Fairbanks
Disorders of Consciousness (Psychology), Martin M. Monti
Social Classification (Sociology), Elizabeth G. Pontikes
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.



Media

Mental Imagery in Psychological Disorders