Stage 2 Registered Report: Propositional Thought Is Sufficient for Imaginal Extinction as Shown by Contrasting Participants With Aphantasia, Simulated Aphantasia, and Controls
Monzel, M., Agren, T., Tengler, M., Karneboge, J., & Reuter, M. (2025). Stage 2 registered report: propositional thought is sufficient for imaginal extinction as shown by contrasting participants with aphantasia, simulated aphantasia, and controls. Psychophysiology, 62(1). doi:10.1111/psyp.14756
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. The 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. 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) and two control groups were subjected to a fear conditioning paradigm followed by imaginal exposure and a reinstatement procedure. During imaginal exposure, a control group (N = 30) stared at a bright screen to disrupt visual imagery by incoming luminance (=simulated aphantasia), while a second control group (N = 30) and participants with actual aphantasia (N = 30) kept their eyes closed. Results showed successful extinction in all groups, thus demonstrating that imaginal extinction is possible using propositional thought. Moreover, exploratory analyses revealed less subjective fear in people with aphantasia during the fear conditioning procedure, potentially due to similar mechanisms as in alexithymia, that is, a decoupling between physiological arousal and emotional experience.
Overview/Introduction
Imaginal exposure is a widely used technique in cognitive behavioral therapy (CBT) for treating anxiety and panic disorders. This method involves imagining fear-inducing scenarios rather than experiencing them in real life, which can be more manageable for patients. Traditionally, it's believed that mental imagery—vividly picturing scenarios in the mind—plays a crucial role in the effectiveness of imaginal exposure. However, some researchers suggest that simply thinking about fear-inducing stimuli, known as propositional thought, might be enough to achieve the desired therapeutic effects. This study explores whether mental imagery or propositional thought is essential for the success of imaginal exposure.
Methodology
The study involved participants with a rare condition called aphantasia, which is the inability to visualize mental images. These participants were compared with two control groups: one group with normal mental imagery abilities and another group whose visual imagery was disrupted by staring at a bright screen (simulating aphantasia). All participants underwent a fear conditioning process followed by imaginal exposure and a reinstatement procedure to test the effectiveness of propositional thought versus mental imagery.
Key Findings
- Successful Extinction Across Groups: All groups, including those with aphantasia and simulated aphantasia, showed successful reduction of fear responses, indicating that imaginal exposure can work through propositional thought alone.
- Reduced Subjective Fear in Aphantasia: Participants with aphantasia reported experiencing less subjective fear during the fear conditioning process. This might be due to a decoupling between physiological arousal and emotional experience, similar to a condition known as alexithymia.
Implications
These findings suggest that imaginal exposure in CBT does not necessarily require the ability to visualize scenarios vividly. This could make therapy more accessible to individuals with aphantasia or those who struggle with mental imagery. Therapists might focus more on guiding patients through propositional thought processes, potentially broadening the scope and accessibility of CBT for anxiety and panic disorders.
Limitations
While the study provides valuable insights, it primarily focuses on a specific aspect of imaginal exposure and involves a relatively small sample size. Further research with larger and more diverse populations is needed to generalize these findings and explore the long-term effects of using propositional thought in therapy.
In conclusion, this research highlights the potential of propositional thought as a viable component of imaginal exposure, offering new avenues for therapeutic practices in treating anxiety and panic disorders.