Imagery Rescripting and Imaginal Exposure for Anxiety Symptoms

Imagery Rescripting and Imaginal Exposure for Anxiety Symptoms: Mechanisms and Outcomes in a Large Analog Sample

This study will recruit 460 participants who self-report high symptoms of anxiety. Participants will be randomly assigned to one of 4 groups: one analog intervention of Imagery Rescripting (IR) for memories, an analog intervention of IR for future events, and analog intervention of Imaginal Exposure (IE) for memories and an analog intervention of IE for future events. We will examine the efficacy and mechanisms behind each intervention.

After being informed about the study potential risks, all patients giving written informed consent will undergo screening to determine eligibility for study entry. They will be randomly assigned to one of four conditions (Imagery rescripting past; Imagery rescripting future; Imaginal exposure past; Imaginal exposure future) at a 1:1:1:1 ratio (n = 115 per group). Participant will be assigned using a variance minimization method that controls for between group variance in continuous and categorical variables- SPIN, ASI-3, OCI-R, GAD-7 and gender with a completely random assignment p random = .2 (for algorithm see Sella et al., 2018). Participants will attend three ~1.5 hour online ZOOM sessions (baseline-assessment and measurement, intervention, post assessment and measurement and follow-up measurement). In this multiple baseline study, participant will enter the intervention phase either 7 or 14 days after the baseline stage. Assessors will be blind to the treatment condition.

Participants in this arm will be asked to decide alongside with the intervention provider (a clinical PhD student or M.A student under the supervision of the principal investigator) to imagine a script based on a past distressing anxiety provoking scenario multiple times while honing in on the most negative aspects.

Participants in this arm will be asked to decide alongside with the intervention provider (a clinical PhD student or M.A student under the supervision of the principal investigator) to imagine a script based on a future distressing anxiety provoking scenario multiple times while honing in on the most negative aspects.

Participants in this arm will be asked to decide alongside with the intervention provider (a clinical PhD student or M.A student under the supervision of the principal investigator) to imagine a script based on a past distressing anxiety provoking scenarios one time while honing in on the most negative aspects. Afterwards they will insert changes into the script that try to help them cope in the imagery: First imagining the scenario from a different character perspective that enacts changes in the memories. Second, The will imagine the scenario again from the original perspective along with changes done by the additional character.

Participants in this arm will be asked to decide alongside with the intervention provider (a clinical PhD student or M.A student under the supervision of the principal investigator) to imagine a script based on a future distressing anxiety provoking scenarios one time while honing in on the most negative aspects. Afterwards they will insert changes into the script that try to help them cope in the imagery: First imagining the scenario from a different character perspective that enacts changes in the memories. Second, The will imagine the scenario again from the original perspective along with changes done by the additional character.

The SPIN is a 17-item validated self-report instrument assessing sum of social phobia symptom intensity over the past week. Possible scores range from 0 (not at all) to 4 (Extremely). Sum scores range is 0-68. Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention ( 7 days after the intervention) and Follow-up (28 days after the intervention)

The ASI-3 is an 18-item validated self-report instrument assessing sum of anxiety sensitivity symptom intensity over the past week. Possible scores range from 0 (not at all) to 4 (Very Much). Sum scores range is 0-72. Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention (7 days after the intervention) and Follow-up (28 days after the intervention)

The OCI-R is an 18-item validated self-report instrument assessing sum of obsessive-compulsive symptom intensity over the past week (Taylor et al., 2007). Possible scores range from 0 (not at all) to 4 (Extremely). Sum scores range is 0-72. Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention (7 days after the intervention) and Follow-up (28 days after the intervention)

The GAD-7 is a 7-item validated self-report instrument assessing sum of generalized anxiety symptom intensity over the past week. Possible scores range from 0 (not at all) to 3 (Almost every day). Sum scores range is 0-21. Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention (7 days after the intervention) and Follow-up (28 days after the intervention)

The OASIS is a 5-item validated self-report instrument assessing sum of anxiety related symptoms, distress avoidance and functioning symptom intensity over the past week (Taylor et al., 2007). Possible scores range from 0 to 4. Sum scores range is 0-20. Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention (7 days after the intervention) and Follow-up (28 days after the intervention)

The TFI is a validated 14 item self-reported instrument assessing average belief in statement that describe the effects of thoughts on reality, objects and actions. Possible scores range from 0 (Do not believe at all) to 100 (completely convinced it is true) in intervals of 10. Average score (0- 100) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention ( 7 days after the intervention) and Follow-up (28 days after the intervention)

The TAFS-R is a validated 19 item self-reported instrument assessing belief in statement that describe the irrational assumption that just because a "bad" thought presents itself to the mind, then it is undeniably followed or accompanied by a specific "bad" action. Possible scores range from 0 (Do not agree) to 4 (Agree alot). Sum score (0- 76) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention (7 days after the intervention) and Follow-up (28 days after the intervention)

Change from Baseline to follow-up in the amount of negative and positive/neutral content details of the memory/future imagery

The Waterloo Image and Memories Interview (WIMI) is a validated structured interview for assessing content of imagery and memories. valence of the details will be scored using a trained coder. change = post-intervention - Baseline Score. The participant provides descriptions of a negative imagery and memory related to his primary symptoms dimension.

Time Frame: Will be measured at Baseline (7 or 14 days before the intervention) and post-intervention ( 7 days after the intervention)

The believability of the negative core-beliefs that the participant link to the negative imagery and memory provided in the WIMI

The Waterloo Image and Memories Interview (WIMI) is a validated structured interview for assessing content of core beliefs related to the future imagery and memory. Believability will be given by the participant for each identified core-belief on a scale of 0 (Do not believe it at all) to 100 (Completely Believe it). change = post-intervention - Baseline Score.

Time Frame: Will be measured at Baseline (7 or 14 days before the intervention) and post-intervention ( 7 days after the intervention)

imaginal Based Approach Test (iBAT) that measures the participant's willingness to interact with pre-scripted distressing scenarios in imagination

The iBAT is currently being developed in our lab. The more levels the participants pass (listen to imaginal scenario in full without pressing "skip") the higher the score he receive (from 0 to 10) There are two versions in the task, each with different 10 scenarios. The versions will be counterbalanced across participants. Recruitment is completed for the first sample and pre-registration is available at the open science framework website: change = post-intervention - Baseline Score. https://osf.io/bp42h/?view_only=5211617cedf94f71a4daa746e98d924a

Time Frame: Will be measured at Baseline (7 or 14 days before the intervention) and post-intervention ( 7 days after the intervention)

the BCSS measures participants' self-beliefs about themselves and others. It is a well validated self-report instrument. It has 24 items total. Each item is scored from 1 (believe it slightly) to 3 (believe it totally) Two sum scores: self (0- 36), other (0-36) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention (7 days after the intervention) and Follow-up (28 days after the intervention)

The SCS is a validated self-report measure, that measures participants' tendency to react to one own suffering and misfortune with self-compassion. It has 12 items with scores ranging from 1 (Almost never) to 5 (Almost always). Sum score (12- 60) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention (7 days after the intervention) and Follow-up (28 days after the intervention)

The IFES is a validated self-report measure, that measures participants' symptoms in reaction to negative future events. It has 24 items with scores ranging from 0 (Not at all) to 4 (A lot). Sum score (0- 96) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention ( 7 days after the intervention) and Follow-up (28 days after the intervention)

The IES is a validated self-report measure, that measures participants' symptoms in reaction to negative past events. It has 22 items with scores ranging from 0 (Not at all) to 4 (A lot). Sum score (0- 88) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention ( 7 days after the intervention) and Follow-up (28 days after the intervention)

The DTS is a validated self-report measure, that measures participants' ability to tolerate distress. It has 15 items with scores ranging from 1 (Completely agree) to 5 (Completely do not agree). Sum score (15- 75) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention ( 7 days after the intervention) and Follow-up (28 days after the intervention)

The ECR-S is a validated self-report measure, that measures participants' behavior in close relationships and maps these behaviors on dimensions of anxious attachment and avoidant attachment. It has 12 items with scores ranging from 1 (Strongly Disagree) to 7 (Strongly Agree). Two average scores: anxious attachment (1-7), other (1-7) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention ( 7 days after the intervention) and Follow-up (28 days after the intervention)

The MCQ-30 is a validated self-report measure, that measures participants' beliefs about their cognitions. It has 30 items with scores ranging from 1 (Do not agree) to 4 (Agree a lot). Sum score (30- 120) Change = 1: (post-intervention score - Baseline Score) 2: (Follow-up score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention), Intervention (immediately after the intervention), post-intervention ( 7 days after the intervention) and Follow-up (28 days after the intervention)

The BCIS is a validated self-report measure, that measures participants' cognitive insight about their symptoms. It has 15 items with scores ranging from 0 (Do not agree) to 3 (Completely Agree). Sum score (0- 45) Change = 1: (post-intervention score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention) and post-intervention ( 7 days after the intervention)

The Locus of control scale measures participants feeling of control over their problems in life. It has 5 items with scores ranging from 1 (Completely not agree) to 5 (Completely Agree). Sum score (5- 25) Change = 1: (post-intervention score - Baseline Score)

Will be measured at Baseline (7 or 14 days before the intervention) and post-intervention ( 7 days after the intervention)

The SAIQ assess attitudes toward mental illness among persons receiving psychiatric treatment. There will be 8 items from that questionnaire: 0 (Not at all) to 3 (A great deal) In general, how much do you tend to worry? How much do you worry about your condition? How much do you worry about losing friends because of your condition? How much do you worry about being unable to work because of your condition? 0 (Strongly agree) to 3 (Strongly Disagree) Do you believe the current treatment to be necessary? I think my condition requires psychiatric treatment I think my condition will go away by itself? If I were to discontinue treatment today I would do fine Change = 1: (post-intervention score - before intervention) 2: (after intervention - before intervention)

Will be measured right before the Intervention, right immediately after the intervention, post-intervention ( 7 days after the intervention)

In this task, participant will classify sentences into two categories (TRUE of FALSE). Sentences are statement taken from the brief core schema scale describing self-beliefs in a positive or negative way. Participants in one block would have to respond TRUE to the positive statements and FALSE to the negative statements. In the second block, the instruction will be reversed, and participants will respond TRUE to the negative statements and FALSE to the positive statements. For each participant a d score will be calculated based on the algorithm in Greenwald, Nosek and Banaji (2003) paper. change = post-intervention - Baseline Score.

Time Frame: Will be measured at Baseline (7 or 14 days before the intervention) and post-intervention ( 7 days after the intervention)

The task requires participants to perform serial additions using the two previously displayed single digits (1-9) in a long running series of digits. They need to add the digits by pressing numbers presented on a circle on screen (2-18). The latency between digits begins at 3s in the initial 3 min block allowing participants to acclimatize to the task itself. The second block is 5-min long with a shorter display latency of 2 s between digits. The third block has a latency of 1s and can last for a maximum of 10 min; however, participants are instructed during the rest period that due to the difficulty they are allowed to end this block at any time by pressing a designated key on the terminals' keyboard. Duration of the third block provides a time measure for resistance to psychological stress change = post-intervention - Baseline Score.

Time Frame: Will be measured at Baseline (7 or 14 days before the intervention) and post-intervention ( 7 days after the intervention)

The first 3 OASIS (see above) items pertaining to frequency, severity and avoidance of anxiety. Two of the following symptom focus area (based on the results from the DIAMOND interview in the baseline assessment): social anxiety (1-7): I was afraid I will say or do the wrong things. I was afraid what other people would think of me. I was afraid others would not accept me. Obsessions and compulsions: three items from the OCI-R that participant scored the highest at. (0-4) Anxiety sensitivity: (0-4) I was anxious that a panic attack would occur. I was anxious I would not be able to handle the panic attack. I was anxious something horrible would happen if a panic attack would occur. I tried to avoid experiencing a panic attack. Generalized anxiety: (0-4) I couldn't worrying or controlling my worry. I was so restless I had trouble sitting down without moving. I was way too worried about different things.

Participants will fill out 9 items pertaining to specific symptoms and mechanisms (Not at all 0 to 100 Very much VAS): I believed that if I thought or imagined an unpleasant event it causes it more likely to happen. I believed that if I thought or imagined I would behave in a negative way it is more likely that I would actually behave this way I believed my thoughts become reality, if I think something it will come true I felt vulnerable I felt weak I tried being understanding and patient towards the aspects in my personality I do not love I try to remind myself that feelings of inadequacy are shared by most people I couldn't handle feelings of stress or distress I did everything to stop feeling stress or distress.

This interview is based on DSM-5 (Diagnostic and Statistical Manual of Mental Disorders fifth edition) diagnostic criteria. It will allow us to detect the presence of social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder and/or panic disorder before the start of the intervention. This interview will be used to exclude participants based on suicidality, psychosis, post-traumatic stress disorder, acute-stress disorder and substance abuse disorder.

Inclusion Criteria: We will recruit participants based on attainment of SPIN score >= 24 and/or ASI-3 scores >=23 and/or OCI-R subscale scores (not including hoarding subscale) >=6 and/or GAD-7 scores >= 9 . Exclusion Criteria: Diagnosis of psychosis, active suicidality, post-traumatic stress disorder, acute stress disorder. Can't report a negative imagery related to a future social scenario. Attending active psychotherapy sessions. Started/stopped taking psychotherapeutic medications in the last 3 months.

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