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Imaginal extinction without imagery: Dissociating the effects of visual imagery and propositional thought by contrasting participants with aphantasia, simulated aphantasia, and controls

DOI: 10.1111/psyp.14271
Monzel, M., Agren, T., Tengler, M., & Reuter, M. (2023). Imaginal extinction without imagery: dissociating the effects of visual imagery and propositional thought by contrasting participants with aphantasia, simulated aphantasia, and controls. Psychophysiology, 60(9). doi:10.1111/psyp.14271

Abstract

Imaginal exposure is a standard procedure of cognitive behavioral therapy for the treatment of anxiety and panic disorders. It is often used when in vivo exposure is not possible, too stressful for patients, or would be too expensive. Peter Lang's Bio‐Informational Theory implies that imaginal exposure is effective because of the perceptual proximity of mental imagery to real events, whereas empirical findings suggest that propositional thought of fear stimuli (i.e., thinking about the stimuli without seeing them in the mind's eye) could be sufficient in therapeutical contexts. Exposure to propositional thought, instead of vivid mental imagery, would be more tolerable for patients since vivid imagery is associated with high emotional distress. To investigate whether mental imagery or propositional thought is crucial for the success of imaginal exposure, participants with the rare state of aphantasia (= absence of sensory mental imagery but with intact propositional thought) and two control groups were subjected to a fear conditioning paradigm followed by imaginal exposure and a reinstatement procedure. During imaginal exposure, control group 1 (N = 30) stared at a bright screen to disrupt visual imagery by incoming luminance (= simulated aphantasia), whereas control group 2 (N = 30) and participants with actual aphantasia (N = 30) kept their eyes closed. The results show […].

Authors

  • Merlin Monzel23
  • Thomas Agren2
  • Matthias Tengler2
  • Martin Reuter15

Understanding Imaginal Exposure in Therapy: A Study on Mental Imagery and Propositional Thought

Overview/Introduction

Imaginal exposure is a technique used in cognitive behavioral therapy to help treat anxiety and panic disorders. It involves patients imagining scenarios that trigger their fears, which can be a substitute for real-life exposure when the latter is impractical or too distressing. Traditionally, it's believed that mental imagery is crucial for this process because it closely resembles real events, triggering similar emotional responses. However, recent research suggests that simply thinking about fear-inducing stimuli, known as propositional thought, might be enough to achieve therapeutic benefits without the distress associated with vivid imagery.

Methodology

To explore whether mental imagery or propositional thought is more effective in imaginal exposure, researchers conducted a study involving three groups:
  • Aphantasia Group: Participants with aphantasia, who cannot form mental images but can think about concepts.
  • Simulated Aphantasia Group: Participants who stared at a bright screen to disrupt visual imagery.
  • Control Group: Participants with normal mental imagery capabilities.
Participants underwent a fear conditioning process, imaginal exposure, and a reinstatement procedure. Their physiological responses, specifically skin conductance, were measured to assess fear levels.

Key Findings

  • Fear Response: The study found that the fear response decreased more quickly in the control group compared to the aphantasia and simulated aphantasia groups when exposed to fear-inducing stimuli.
  • Emotional Activation: The results suggest that vivid mental imagery might not be necessary for imaginal exposure to be effective. Instead, propositional thought could suffice, making the process more tolerable for patients who experience high distress from vivid imagery.

Implications

These findings could significantly impact how therapists approach treatment for anxiety and panic disorders. By focusing on propositional thought rather than vivid imagery, therapy could become more accessible and less distressing for patients, particularly those who struggle with intense emotional responses to mental imagery.
  • Practical Application: Therapists might consider incorporating techniques that emphasize propositional thought to make therapy more comfortable for patients.
  • Broader Reach: This approach could also reduce costs and logistical challenges associated with in vivo exposure therapy.

Limitations

While the study provides valuable insights, there are some limitations:
  • Sample Size: The study involved a relatively small number of participants, which may affect the generalizability of the results.
  • Specific Population: The findings are based on individuals with aphantasia and may not fully apply to the general population.
Overall, this research highlights the potential for mo...