There is now a widespread recognition of the importance of mental imagery in a range of clinical disorders (1). This provides the potential for a transdiagnostic route to integrate some aspects of these disorders and their treatment within a common framework. This opinion piece argues that we need to understand why imagery is such a central and recurring feature, if we are to progress theories of the origin and maintenance of disorders. This will aid us in identifying therapeutic techniques that are not simply targeting imagery as a symptom, but as a manifestation of an underlying problem. As papers in this issue highlight, imagery is a central feature across many clinical disorders, but has been ascribed varying roles. For example, the involuntary occurrence of traumatic memories is a diagnostic criterion for PTSD (2), and it has been suggested that multisensory imagery of traumatic events normally serves a functional role in allowing the individual to reappraise the situation (3), but that this re-appraisal is disabled by extreme affective responses. In contrast to the disabling flashbacks associated with PTSD, depressed adults who experience suicidal ideation often report “flash forward” imagery related to suicidal acts (4), motivating them to self-harm. Socially anxious individuals who engage in visual imagery about giving a talk in public become more anxious and make more negative predictions about future performance than others who engage in more abstract, semantic processing of the past event (5). People with Obsessive Compulsive Disorder (OCD) frequently report imagery of past adverse events, and imagery seems to be associated with severity (6). The content of intrusive imagery has been related to psychotic symptoms (7), including visual images of the catastrophic fears associated with paranoia and persecution. Imagery has been argued (8) to play a role in the maintenance of psychosis through negative appraisals of imagined voices, misattribution of sensations to external sources, by the induction of negative mood states that trigger voices, and through maintenance of negative schemas. In addiction and substance dependence, Elaborated Intrusion (EI) Theory (9, 10) emphasizes the causal role that imagery plays in substance use, through its role in motivating an individual to pursue goals directed toward achieving the pleasurable outcomes associated with substance use. In this opinion piece, we would like to put forward the proposition that the motivating role that imagery plays in behavior may be a key reason for its presence in this wide range of psychopathologies, and that understanding its motivating role can help us identify common features in disorders and their treatments. It has already been recognized that the link between imagery and affect gives imagery a causative role in affective disorders (11), with the emotional amplifier hypothesis suggesting that in bipolar and anxiety disorders, state-congruent imagery leads to further affective responses, in a vicious cycle. Within EI Theory, the affective consequences of imagery are also used to explain why a cycle of elaboration follows an initial intrusive thought. The intrusive thoughts themselves are seen as the product of associative processes relating to both environmental cues and cognitions. Previous work on EI Theory focused initially on desires, and then on motivation in general. Our suggestion here moves a step further, highlighting its potential relevance to dysfunctional motivational imagery in multiple disorders.
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