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A review on mental imagery in fear conditioning research 100 years since the
'Little Albert' study

Article  in  Behaviour Research and Therapy · January 2020

DOI: 10.1016/j.brat.2020.103556

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 Behaviour Research and Therapy 126 (2020) 103556

Contents lists available at ScienceDirect

Behaviour Research and Therapy

journal homepage: www.elsevier.com/locate/brat

A review on mental imagery in fear conditioning research 100 years since T

the ‘Little Albert’ study
Gaëtan Mertensa,∗, Angelos-Miltiadis Krypotosa,b, Iris M. Engelharda
a
Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands
b
Health Psychology Research Group, KU Leuven, Leuven, Belgium

ARTICLE INFO ABSTRACT

Keywords: Since the seminal ‘Little Albert’ study by Watson and Rayner (1920), fear conditioning has become one of the
Imagery most commonly used paradigms for studying the etiology of anxiety-related disorders. In a fear conditioning
Fear procedure, a (neutral) conditioned stimulus (CS) is paired with an aversive unconditioned stimulus (US), re-
Conditioning sulting in fear-related conditioned responses (CRs) to the CS. Whereas fear conditioning research initially fo-
Mental imagery
cused on observable elements in the environment (i.e., CSs, USs, and their contingency) and their effects (i.e.,
Intrusive memories
CRs), subsequent research indicated that attention should also be given to unobservable mental events (e.g.,
intrusive memories of aversive outcomes) to more fully account for the symptomatology of anxiety disorders. In
this paper, we review the research relating to four major research questions on the relationship between mental
imagery and fear conditioning: (1) Can mental imagery substitute for actual stimulus administration? (2) Can
mental imagery inflate CRs? (3) Can fear conditioning result in the installment of mental images as CRs (i.e.,
intrusions)? (4) Can mental imagery-based interventions reduce CRs? For all these research questions, tentative
confirmatory evidence has been found and these findings corroborate contemporary conditioning theories.
Nonetheless, we point to several open questions and methodological issues that require further research.

1. Introduction ritory of behaviorism (Skinner, 1963; Watson, 1913). Behaviorism fo-

cuses on analyzing behavior in terms of observable environmental
Since the publication of Watson and Rayner's seminal ‘Little Albert’ elements (such as CSs and USs) and their effects (observable CRs),
study (Watson & Rayner, 1920), fear conditioning has become one of without needing to look into the ‘black box’ of mental events. In Wat-
the most widely used paradigms to study the acquisition, extinction, son's well-known paper ‘Psychology as the behaviorist views it’
and return of fear (Mineka & Zinbarg, 2006; Vervliet, Craske, & (Watson, 1913), he wrote that: “we can write a psychology […] [and]
Hermans, 2013). The core procedural elements of the fear conditioning never use the terms consciousness, mental states, mind, content, in-
paradigm are the pairing of an initially neutral stimulus, called the trospectively verifiable, imagery, and the like” (p. 166). However, beha-
conditioned stimulus (CS), with an aversive unconditioned stimulus viorism became criticized from the 1950–1960s onwards for several
(US), resulting in the establishment of conditioned responses (CRs) to reasons, including that it failed to account for subjective experiences
the CS, even in absence of the US. Though certain aspects of Watson and (Graham, 2019). For example, fear conditioning seems to optimally
Rayner's original study were criticized (see Fridlund, Beck, Goldie, & model posttraumatic stress disorder (PTSD; i.e., persistent anxiety-re-
Irons, 2012; Hermans, Boddez, & Vervliet, 2019), many subsequent lated responses due to the direct experience with a traumatic event,
studies have demonstrated that fear conditioning can install behavioral, particularly when presented with associated cues), but core PTSD
cognitive, and physiological responses related to fear. To date, fear symptoms are the distressing and vivid re-experiencing of the traumatic
conditioning is one of the dominant paradigms for studying the etiology event. Such intrusive images of aversive experiences in the past or
of fear and anxiety-related disorders (Beckers, Krypotos, Boddez, anticipated in the future are also common in other anxiety-related
Effting, & Kindt, 2013; Field, 2006; Mineka & Zinbarg, 2006). disorders (Brewin, Gregory, Lipton, & Burgess, 2010; Engelhard, van
The ‘Little Albert’ study also pioneered the new psychological ter- den Hout, Janssen, & van der Beek, 2010; Holmes & Mathews, 2010),

∗
Corresponding author. Department of Clinical Psychology, Heidelberglaan 1, 3584CS, Utrecht University, Utrecht, the Netherlands.
E-mail address: [email protected] (G. Mertens).

https://doi.org/10.1016/j.brat.2020.103556
Received 30 August 2019; Received in revised form 9 January 2020; Accepted 14 January 2020
Available online 22 January 2020
0005-7967/ © 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/BY/4.0/).
G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

but they fall outside of the scope of behaviorism as defined by Watson.1 can be sensitive to spurious factors, such as demand characteristics and
Most likely due to these historical roots, mental imagery, and more socially desirable responding (e.g., Allbutt, Ling, Heffernan, &
generally emotional episodic memory (Dunsmoor & Kroes, 2019), has Shafiullah, 2008; Intons-Peterson, 1983). Therefore, other ways to
received little attention within fear conditioning research, despite its measure mental imagery have been used, such as behavioral tasks,
clinical relevance. Fear conditioning research could, nevertheless, profit psychophysiological measures, and functional neuroimaging. We will
from more attention for mental imagery and images. To illustrate, briefly introduce these measures (for a more detailed overview and
concerns have been raised that fear conditioning is too focused on review of imagery measures see D. G. Pearson, Deeprose, Wallace-
simple stimuli (e.g., geometric shapes and electric shock; Mertens, Hadrill, Heyes, & Holmes, 2013).
Wagensveld, & Engelhard, 2019; Scheveneels, Boddez, Vervliet, &
Hermans, 2016), and neglects clinically relevant behaviors (e.g., 1.1.2.1. Self-report measures
avoidance behaviors; Krypotos, Vervliet, & Engelhard, 2018) and phe- 1.1.2.1.1. Measures of imagery about specific objects or
nomena (e.g., intrusions; Wegerer, Blechert, Kerschbaum, & Wilhelm, situations. When participants are instructed to imagine a specific
2013). Studying mental images and memories could help fear con- object or situation, they can be asked to rate its vividness on Likert
ditioning research to become more clinically relevant and provide im- scales or Visual Analogue Scales (e.g., “How clear did you find the
portant insights into the etiology, maintenance, and treatment of an- image of the memory that you just recalled?“; Mertens et al., 2018b).
xiety-related disorders. For instance, in recent years, research on mental Likewise, other dimensions of mental images can be assessed such as
imagery and how it is involved in psychopathology has been steadily emotionality, distress, valence, fear, and arousal (e.g., Dibbets,
expanding (for reviews see Holmes & Mathews, 2010; Ji, Heyes, Lemmens, & Voncken, 2018; Kearns & Engelhard, 2015; Mueller,
MacLeod, & Holmes, 2016), and it has shown that therapeutic inter- Sperl, & Panitz, 2019).
ventions that make use of mental imagery are promising for the treat- Another way to probe mental imagery is to ask participants to
ment of anxiety-related disorders (Engelhard, McNally, & van Schie, complete a structured diary at home or to press a computer key
2019; Morina, Lancee, & Arntz, 2017). Translation of these insights to whenever an image comes to mind in the laboratory (Berntsen, 2009;
conditioning procedures could help to better understand the underlying Lau-Zhu, Holmes, & Porcheret, 2018). Such an approach has been used
mechanisms of such interventions. in the context of involuntary memory of past and future mental events
Given these considerations, we think a systematic review of the (e.g., Cole, Staugaard, & Berntsen, 2016; Schlagman & Kvavilashvili,
available research regarding mental imagery in the context of fear 2008; Wegerer et al., 2013).
conditioning is warranted. Therefore, we first introduce contemporary 1.1.2.1.2. Measures of trait imagery ability. Mental imagery is also
definitions and measures of mental imagery. Next, we briefly review the often considered to be a stable inter-individual trait that can be assessed
available studies on mental imagery in fear conditioning that have been using questionnaires. Relevant questionnaires include the
previously reviewed in the seminal paper by Dadds, Bovbjerg, Redd, Questionnaire Upon Mental Imagery (QUMI; Sheehan, 1967),
and Cutmore (1997), before moving on to our updated review on this Vividness of Visual Imagery Questionnaire-2 (VVIQ-2; Marks, 1995),
topic. We conclude this paper with an integration of this research into Spontaneous Use of Imagery Scale (SUIS; Reisberg, Pearson, & Kosslyn,
contemporary models of fear conditioning and provide an outline of 2003), and the Plymouth Sensory Imagery Questionnaire (Psi-Q;
open questions and avenues for future research. Andrade, May, Deeprose, Baugh, & Ganis, 2014). Little information
about the reliability and validity of these questionnaires is available (D.
1.1. Definition, measurement, and control conditions of mental imagery G. Pearson et al., 2013). In a recent validation study, the Psi-Q
questionnaire showed good internal (.96) and test-retest (.71)
1.1.1. Definition reliability (Andrade et al., 2014) and significant correlations with two
Imagery is typically defined as the mental simulation of stimuli or other questionnaires (with VVIQ: r = 0.67; with SUIS: r = 0.40).
situation in the absence of physical stimulation and can involve mul- However, these questionnaires tend to focus on different aspects of
tiple sensory modalities (Kosslyn, Thompson, & Ganis, 2006). It is also mental imagery. Some focus on visual mental imagery specifically,
often referred to as “seeing with the mind's eye” or “hearing with the whereas others also focus on imagery in other sensory modalities (see
mind's ear” (Holmes & Mathews, 2010; Kosslyn, Ganis, & Thompson, D. G. Pearson et al., 2013).
2001). Several theorists have proposed that there is overlap between
processes involved in mental imagery and actual perception (Farah, 1.1.2.2. Behavioral tasks. The study of mental imagery has been
1989; Kosslyn et al., 2001; Holmes & Mathews, 2010). In support of advanced by its linkage to working memory (WM) models (Andrade,
such theories, neuroimaging studies have indicated that engaging in Kavanagh, & Baddeley, 1997; Baddeley & Andrade, 2000). According to
mental imagery of stimuli activates many of the same brain areas as WM models, mental operations are executed by a limited pool of mental
those involved in actually perceiving stimuli (Ganis, Thompson, & resources. Often, two different subcomponents of WM are distinguished
Kosslyn, 2004). However, it may be noted that there is ongoing debate (next to an overarching central executive): the visuo-spatial sketchpad
about whether mental imagery reflects ‘mental pictures in the brain’ and the phonological loop (Baddeley, 2012). Visual mental imagery has
(pictographic theories) or propositional knowledge about the world been coupled to the visuo-spatial sketchpad (Baddeley & Andrade,
(Kosslyn et al., 2006; Pylyshyn, 2003; Thomas, 2019). 2000). Due to the limited capacity of the WM systems, their
involvement can be assessed by loading subcomponents of WM by
1.1.2. Measurement having participants conduct concurrent WM tasks. Indeed, research has
Mental imagery is typically measured with self-reports, but these shown that concurrent visuo-spatial tasks disrupts visual mental
imagery, and vice versa (i.e., engaging in visual mental imagery
interferes with the execution of visuo-spatial tasks) (Baddeley &
1
Watson's behaviorism is sometimes referred to as ‘methodological beha- Andrade, 2000; Lau-Zhu, Holmes, Butterfield, & Holmes, 2017).2
viorism’, focusing on observable procedures and behaviors, and it explicitly Hence, decreased performance on visuo-spatial WM tasks may be
rejected the study of unobservable events such as mental imagery (see quotes
above). Radical behaviorism advocated by B. F. Skinner, however, does include
2
analysis of events that are only observable for the organism itself, including However, visual mental imagery also affects concurrent tasks with other
mental imagery (Anderson, Hawkins, Freeman, & Scotti, 2000). Nonetheless, modalities (auditory, tactile), presumably due to general load effects (see van
mental imagery has only received minimal attention in the behavior-analytic den Hout & Engelhard, 2012). The extent to which WM resources are modality-
tradition (Thomas, 2019). specific or nonspecific is a debated issue (Camos, 2017).

2
G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

used to establish the involvement of mental imagery. Conversely, visuo- nonetheless engage in visual imagery. However, a drawback is that
spatial WM tasks can also be used as an intervention to interfere with there is little direction for participants on what they should do. This
mental imagery (e.g., Baddeley & Andrade, 2000; Leer, Engelhard, may be particularly problematic when participants are exposed to vivid
Altink, & van den Hout, 2013; van den Hout & Engelhard, 2012). stimuli material. Under such conditions, it is possible that they will
spontaneously engage in mentally rehearsing this information (i.e.,
1.1.2.3. Psychophysiological correlates have involuntary thoughts) (Ball & Brewin, 2012; James et al., 2016),
1.1.2.3.1. Defensive responses elicited by mental imagery. According potentially reducing differences between this control condition and the
to the bio-informational model of mental imagery (Lang, 1979), mental experimental condition.
imagery of emotional stimuli elicits physiological responses that are
comparable to direct experience with the imagined stimuli. In support 1.1.3.2. Recall only or imaginal exposure. Another control condition is to
of this theory, experiments probing different sorts of mental imagery ask participants to recall their memory of a certain stimulus or
have demonstrated that it can elicit physiological responses that situation. This condition is typically used to control for the effects of
correspond to the instructed content of the imagery (Cuthbert et al., imaginal exposure in studies in which emotional memories need to be
2003; Vrana & Lang, 1990). As such, physiological responses related to reprocessed in a certain way such as, for instance, when using lab
fear and negative affect can be used as a manipulation check to ensure models of imagery rescripting or Eye Movement Desensitization and
that participants engage in aversive mental imagery (Ji et al., 2016), or Reprocessing (EMDR) therapy (see below). Prolonged imaginal
as outcome measure to assess the emotional evocative power of mental exposure is an effective imagery-based procedure for reduction of fear
images (e.g., Kearns & Engelhard, 2015). These include increased skin (e.g., Foa & Rothbaum, 1998), and merely thinking about an emotional
conductance responses, heart rate acceleration, potentiation of the memory in the lab can reduce the emotional distress prompted by
startle reflex, and pupil dilatation (Cuthbert et al., 2003; Mueller et al., subsequent recollection (e.g., van Veen, van Schie, van de Schoot, van
2019; Vrana & Lang, 1990). den Hout, & Engelhard, 2019). Alternatively, thinking about an
1.1.2.3.2. Functional neuroimaging of mental imagery. Involvement aversive memory may also lead to fear inflation (see below). As such,
of mental imagery can also be established using functional ‘recall only’ is not a passive control condition. Furthermore, it is
neuroimaging, given that mental imagery activates brain regions that worthwhile to note that ‘recall only’ is a term used in the literature
correspond with actual perception of the imagined stimuli (Ganis et al., for this type of manipulation, but does not necessarily imply the recall
2004). In fact, brain activation in these regions appear to correlate of a long-term memory. Therefore, it could also be referred to as
directly with rated vividness of mental imagery (Cui, Jeter, Yang, imaginal exposure or mental rehearsal. However, to maintain
Montague, & Eagleman, 2007). As such, fMRI brain activation in areas consistency with the reviewed papers, we will refer to this control
previously related to mental imagery can be used as a measure for the condition as ‘recall only’.
involvement of mental imagery (e.g., Reddan, Wager, & Schiller, 2018).
1.1.3.3. Verbal processing. A third control condition for visual mental
1.1.2.4. Conclusion about mental imagery measures. The involvement of imagery is to ask participants to engage in verbally based processing.
mental imagery can be assessed with a heterogenous set of methods. This approach has been used in studies by Holmes and colleagues (for a
Prior research indicates that there is a degree of correspondence review see Holmes & Mathews, 2010), which showed that visual mental
between self-report measures, behavioral measures, and imagery elicits stronger emotional responses compared to verbal
psychophysiological measures of mental imagery (e.g., Cui et al., processing. However, it remains unclear whether this is also the case
2007; Miller et al., 1987). These sources of information point to a for mental imagery in other sensory modalities (i.e., auditory, tactile,
construct that is reliable (i.e., stable inter-individual difference and olfactory, etc.). Moreover, there is evidence that verbal information
measurable within laboratory tasks) and valid (i.e., convergence across (without instructions to engage in mental imagery) can also strongly
measures and linked to symptoms in psychological disorders; for elicit emotional reactions (Costa, Bradley, & Lang, 2015; Mertens,
evidence regarding the latter point see Muse, McManus, Hackmann, Boddez, Sevenster, Engelhard, & De Houwer, 2018) and that (visual)
Williams, & Williams, 2010). However, it should be noted that a mental images are related to, rather than independent of, (verbal)
number of other studies have raised some concerns about expectations and likelihood estimations (Carroll, 1978; Muse et al.,
inconsistencies in the factor structure of mental imagery 2010).
questionnaires (e.g., Andrade et al., 2014; Campos & Pérez-Fabello,
2005) and the reliability of the correlations between different measures 1.1.3.4. Irrelevant visual imagery. Another approach is to ask
of mental imagery (e.g., Laor et al., 1999). Therefore, the participants to engage in irrelevant mental imagery, such as imaging
correspondence between different imagery measures and the structure a cat meowing (Jones & Davey, 1990) or a car ride (Arabian, 1982). An
of the latent construct require further research. We revisit this issue in advantage of this approach is that it controls for the general effects of
the Discussion. engaging mental imagery and reduces the chances of spontaneous
imagery of the relevant materials. A drawback is that it is an ‘active’
1.1.3. Control conditions for mental imagery control condition that may produce certain effects (e.g., engaging in
Besides the operationalization and measurement of mental imagery, irrelevant positive imagery may reduce fear; Zbozinek, Holmes, &
experimental studies investigating mental imagery (such as the ones Craske, 2015), which can complicate the interpretation of effects
included in this review) require appropriate control conditions. In the relative to the experimental (relevant imagery) condition.
next paragraphs, we briefly introduce five different control conditions
that are often used to investigate mental imagery within fear con- 1.1.3.5. Actual stimulus administration. Finally, participants can be
ditioning research. exposed to the actual stimulus they are asked to imagine in the
experimental condition (e.g., Grégoire & Greening, 2019). A potential
1.1.3.1. No imagery instructions. One possible control condition is to drawback is that the effects of mental imagery may generally be weaker
give participants no specific instructions about mental imagery in the than those of actual stimulus administration (Dadds et al., 1997).
control condition (e.g., ask participants to imagine one stimulus, but Hence, weaker effects in the mental imagery condition compared to the
not another; see Grégoire & Greening, 2019). An advantage of this actual stimulus administration condition are expected. However, this
approach is that participants are not attended in the control condition does not necessarily imply that mental imagery had no effects.
to the fact that mental imagery is investigated, thereby reducing Therefore, it may be recommended to supplement this control
demand bias (Orne, 1962) and the possibility that participants condition with one of the other control conditions mentioned

3
G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

previously to establish whether mental imagery had any effects at all.

Sample size

14

88

24

40
1.1.3.6. Conclusion regarding the control conditions for mental
imagery. The choice of an appropriate control for mental imagery

Retention of conditioned SCRs in a test phase for the

experimental group, but not for the neutral imagery
visual CSs. No correlation between imagery ability
Slower SCR habituation for participants with vivid

A mentally imagined CS can become conditioned,

depends both on theoretical considerations (e.g., whether or not

Stronger SCRs to the tones in a test phase for the

though CRs were less strong compared to actual

groups that were asked to imagine the tone and

pairings of the tone and shock compared to the
groups that were asked to imagine contiguous
visual mental imagery is independent of verbal processing) and the
potential interfering factors that one wants to control for (e.g.,

or aversive imagery control conditions

spontaneous mental imagery; experimental demand effects;
habituation). A useful approach is to use multiple control conditions
(e.g., no imagery and actual stimulus administration) to establish the
robustness and generalizability of the effects of mental imagery across

and imagery conditioning.

different conditions.

Abbreviations: QUMI = Questionnaire Upon Mental Imagery; GTVI = Gordon Test of Visual Imagery; SCR = Skin Conductance Response; CR = Conditioned Response.
shock separately
Main findings
1.2. Previous work reviewed by Dadds et al. (1997) and introduction of the
current review

imagery
Early research on the role of imagery in classical conditioning has
been reviewed and integrated by Dadds et al. (1997). Of the reviewed

Post-experimental questionnaire about

studies, only four have focused specifically on fear conditioning (the

experiment and difficulty of the

others focused on conditioned nausea in chemotherapy, vestibular

participants' hunches about the

conditioning, and the habituation of orienting reflexes to novel stimuli).

Mental imagery measure(s)

We have summarized the main findings of these four studies in Table 1.
Based on the reviewed studies, Dadds et al. (1997) concluded that: “The
evidence suggests that mental imagery can facilitate or diminish the outcome
of classical conditioning in humans and, more tentatively, that mental

imagery task
images can substitute for actual US and CS in autonomic conditioning” (p.
89). However, of the available studies for fear conditioning, one did not QUMI

QUMI
GTVI

NA
include an appropriate control condition to assess the effect of visual
mental imagery (Drummond, White, & Ashton, 1978), and another one

Irrelevant (neutral) imagery: “Think of a cat meowing

In two control conditions (one for delay and one for

Half of the participants saw actual visual CSs. The

experimenter mention the word ‘tone’ and ‘shock’

did not include any measure of mental imagery (Yaremko & Werner,

Irrelevant (aversive) imagery: “Think of someone

separately imagine the tone and shock (i.e., no

two groups (imagery, actual CSs) were further

trace conditioning) participants were asked to

1974) (see Table 1). As such, with addition of the study by Holzman divided in unpaired and unreinforced groups

emphasis on their contiguity) whenever the

and Levis (1991), the results of these initial studies can be considered to
Studies investigating the impact of mental imagery on fear conditioning reviewed by Dadds et al. (1997).

provide preliminary, but not conclusive, support for the idea that

trying to stick a needle into your eye.”

mental imagery can serve as a replacement for the actual administra-
when the word ‘think’ is presented.”

tion of the CS and US. Additionally, the study of Jones and Davey
(1990) provides initial support for the idea that mental imagery during
an extinction procedure can maintain conditioned responses (as mea-
sured with skin conductance responses). Since the initial review of
Control condition(s)

Dadds et al. (1997), more mental imagery studies have been published
in which a fear conditioning procedure was used. respectively
In the following sections, we provide an overview and updated re-
view of the studies in which mental imagery was investigated within
NA

fear conditioning research since the review by Dadds et al. (1997). It is

important to clarify that, within the context of clinical psychology and
prior to the presentation of a shock (US): “When I tell
you to imagine one of the slides, I would like you to close

After a delay or trace conditioning procedure (with a

Half of the participants were asked to imagine a CS
After an instructed (i.e., unreinforced) conditioning

Participants were asked to think about a loud tone

first conditioning phase whenever the word ‘think’

phase, participants were asked to imagine a shock

followed by the shock whenever the experimenter

psychopathology, the focus of mental imagery is typically on visual

(imagine the tone and their reaction to it) from a

tone and a shock), half of the participants were

mental imagery. This is most likely because the visual sensory modality
asked to imagine the tone being immediately

is generally regarded as the most important sensory modality for hu-

your eyes and imagine that slide appearing.”

mans (e.g., Ripley & Politzer, 2010). As such, nearly all of the studies
we will review have focused on visual mental imagery (though some
have also focused on tactile mental imagery; i.e., imagining an electric
said the words ‘tone … shock’
was presented on the screen
whenever they heard a tone

shock). However, imagery in other modalities (e.g., auditory, tactile,

olfactory) can also be implicated in PTSD and other anxiety-related
Imagery instructions

disorders (Engelhard, van den Hout, Arntz, & McNally, 2002;

Hackmann, Ehlers, Speckens, & Clark, 2004).

2. Methods

To identify relevant studies, we conducted a systematic biblio-

Drummond et al.

Jones and Davey

Levis (1991)

graphical search. Due to the heterogeneity in the methods, measures,

Holzman and

Yaremko and

and research questions (see below), we decided to refrain from quan-

Werner
(1978)

(1990)

(1974)
Reference

titative analyses (e.g., a meta-analysis) and to provide a systematic

Table 1

review instead. PRISMA-guidelines were followed for the screening,

selection, and presentation of relevant studies (Moher et al., 2015).

4
G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

2.1. Search strategy question, we identified three other thematic research questions in the
selected studies: (1) Whether mental imagery can lead to fear inflation
Three digital databases (PsycINFO, Pubmed, Embase) were used to (derived from the fear incubation theory; see Eysenck, 1968); (2)
search for relevant articles published between January 1st, 1995 and Whether CSs can evoke visual mental images as conditioned responses;
June 14th, 2019. The keywords selected for the search were split into and (3) Whether conditioned fear responses can be reduced though
two categories: Imagery and Conditioning. These subcategory keywords mental imagery-based interventions. We will discuss the studies in re-
were connected with the boolean operator “OR”, and the two sub- lation to these four research questions. To illustrate the clustering of
category search terms were merged with the boolean operator “AND”. these research questions, we created a graphical network (using the
Keywords used for the search engines Embase, Pubmed, and PsycINFO “visNetwork” R package; Almende, Benoit, & Robert, 2019) of the
were: image*, mental image*, mental representation*, cognitive re- cross-referencing of the included articles and 4 central theoretical pa-
presentation*, imagery rescripting, intrusive image*, future thinking, pers relating to each of the research questions (see Fig. 2). This graph
counterfactual thinking, image processing, conditioning, classical con- shows distinct clusters relating to the different research questions, with
ditioning, Pavlovian conditioning, respondent conditioning, associative a central position for research on mental-imagery based interventions
learning, and association learning (truncation applied to include var- to reduce conditioned fear. Please note that this figure is not meant as a
iations on image and representation such as imagery, images, and re- network analysis of this research area, but merely as a graphical illus-
presentations).3 Additional relevant studies were identified through the tration of the clusters of research on these four distinct research ques-
reference list of relevant publications and by a prior search conducted tions. Furthermore, Table 2 provides an overview of the included stu-
by students on 13th April 2018 (using the same search terms, but in- dies and their key procedural characteristics. A more detailed table can
cluding Thesaurus Map Terms in the PsycINFO database [imagery and be found in the Supplementary Materials.
conditioning] and Medical Subject Headings for PubMed [imagery,
conditioning, classical conditioning, and association learning]). One
additional relevant study was identified by a reviewer during the re- 3.1. Mental images as replacement for actual stimuli
view process of this article. Fig. 1 provides an overview of the search
strategy. Similar to the main theme of the Dadds et al. (1997) review, many
of the studies we identified examined whether mental imagery can
substitute the actual administration of the CS, US, or CS-US con-
2.2. Screening process and study exclusion criteria
tingency.4 Regarding whether mental imagery of the CS can substitute
the actual administration of the CS, four studies were identified. Par-
The identified studies were screened by the first author and a re-
ticularly, Reddan et al. (2018) asked participants to imagine the CS+
search assistant on the basis of their title and abstract to determine their
and CS- to the best of their ability when they were cued following a fear
potential relevance for our systematic review. Screening was done in-
conditioning phase with tones. No US was administered during this
dependently (using an online tool: https://rayyan.qcri.org/) and con-
imagery phase. In two control conditions, participants were shown ei-
flicts in identification were resolved through discussion. The full texts
ther actual unreinforced presentations of the CS+ and CS- or were
of 33 identified publications were further screened for final inclusion.
asked to engage in irrelevant mental imagery when cued (i.e., imagine
Inclusions criteria were: (1) the use of a fear conditioning procedure;
birds singing and rain falling). The authors observed comparable fear
and (2) the use of an imagery manipulation or measure. An additional
extinction (measured by skin conductance) in the imagery condition
13 publications were further excluded based on these criteria, resulting
and the actual administration condition, but not in the irrelevant
in a final selection of 20 publications (reporting 25 separate studies).
imagery condition. Furthermore, extinction in the relevant imagery and
actual presentations conditions was predicted by activation in similar
2.3. Data extraction and bias assessment brain regions centered on the ventromedial prefrontal cortex, amyg-
dala, and auditory cortex. However, nucleus accumbens activation ex-
Data extraction focused on the posed research question, population, clusively predicted extinction success in the relevant imagery group.
instructions for introducing mental imagery, control condition(s), Similarly, Agren, Björkstrand, and Fredrikson (2017) and Grégoire and
mental imagery measures, type of CS and US, outcome measures, and Greening (2019) found that mental imagery can induce extinction and
sample size (based on the Population, Intervention, Comparator, and interfere with memory reconsolidation, comparable to actual stimulus
Outcome, or PICO framework; Huang, Lin, & Demner-Fushman, 2006). administration. Finally, in a study by Meulders, Harvie, Lorimer
Data extraction was conducted by the first author (GM) and in- Moseley, and Vlaeyen (2015), participants saw pictures of hand
dependently checked by the second author (AMK). Bias assessment movements (i.e., open hand or fist). They were asked to make left-right
focused on whether the studies included adequate control conditions judgements of the hands, which requires motor imagery. Following the
and manipulation checks for the involvement of mental imagery (see left-right judgement, one of the hand movements was paired with a
Table 2 and the table in the Supplementary Materials). mild electric shock. Meulders et al. (2015) observed conditioned fear
and fear generalization to similar hand movements as indicated by
3. Results subjective ratings, suggesting that mental motor imagery resulted in the
acquisition of movement-related fear. However, due to the omission of
As discussed previously, the studies reviewed by Dadds et al. (1997) an appropriate control condition in this study (e.g., no left-right jud-
mostly focused on whether imagined stimuli can act as replacements for gement task), no firm conclusions about mental imagery can be drawn.
the actual administration of CSs and USs (with the exception of the An alternative explanation could be that the pictures rather than ima-
study by Jones & Davey, 1990). In addition to this first research gery of the hand movements became conditioned. These four studies

3 4
PubMed search script: (((((((((((((“Image*") OR “Mental image*") OR Note though that some of these studies we describe in this section were
“Mental representation*") OR “Cognitive representation*") OR “Intrusive motivated by the fear incubation theory rather than focused on investigating
image*") OR “Future thinking”) OR “Counterfactual thinking”) OR “Image whether mental imagery can substitute for physical stimulus presentation (see
processing")) AND ((((((“Association learning”) OR “Associative learning”) OR Fig. 2). Nonetheless, we think that those studies are also relevant for the latter
“Respondent conditioning”) OR “Pavlovian conditioning”) OR “Classical con- research question and therefore we already introduce these studies already
ditioning”) OR “Conditioning"))) Sort by: Best Match Filters: Publication date here. A more detailed description of the fear incubation theory and the relevant
from 1995/01/01; Humans. research is provided in section 3.2.

5
G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

Fig. 1. Flowchart for the literature search.

thus provide some evidence that, following an acquisition phase with in a study from our lab (Krypotos et al., 2019; Experiment 1), partici-
actual pairings of the CS and the US, mental imagery can substitute for pants were asked to imagine that a previously shown neutral CS (i.e., a
actual CS administration in subsequent experimental phases (for related blue square) was followed by a shock. Compared to a control condition
evidence in the context of evaluative conditioning, see Lewis, O'Reilly, (between-subjects) in which participants were asked to imagine the CS
Khuu, & Pearson, 2013). and a neutral tone, the experimental condition resulted in higher
Other studies have focused on imagination of the US. For instance, avoidance responses (i.e., pressing the spacebar to cancel US adminis-
in the study of Mueller et al. (2019) participants were trained to ima- tration) in a subsequent test phase. The results of these studies suggest
gine stepping on a thumbtack whenever they saw a particular geometric that mental imagery of the CS-US contingency can result in the in-
shape. This shape was subsequently paired with a neutral face as the CS. stallation (Krypotos et al., 2019) and preservation (Joos et al., 2012) of
Their results indicated that the imagery cue elicited physiological de- conditioned avoidance and fear responses.
fensive responding (i.e., skin conductance responses, increased heart
rate), which suggests that participants did indeed engage in mental 3.2. Mental imagery and fear inflation
imagery of the US. Furthermore, conditioning by pairing CSs with the
cues for mental imagery was observed using aversiveness ratings of the Some of the selected studies have been inspired by the fear in-
CS and heart rate acceleration, though not with skin conductance re- cubation theory (Eysenck, 1968, 1979; McAllister & McAllister, 1967).
sponses. They replicated the findings in a second study using different According to the fear-incubation theory, offline processing of traumatic
imagery instructions (i.e., imagine a shock). Similar findings that US experiences may contribute to the development of pathological fear and
imagery can replace actual US administration were found by Arntz, anxiety, resulting in strengthened conditioned responses over time.
Spit, and Merckelbach (1997), Davey and Matchett (1994), and Such offline processing may consist of repeatedly reactivating the
Krypotos, Mertens, Leer, and Engelhard (2019; Experiment 2). memory of the US, the CS-US contingency, and/or the CS-CR con-
Finally, two studies focused on the effects of mental imagery of the tingency.
CS-US contingency (Joos, Vansteenwegen, & Hermans, 2012; Krypotos Several studies have examined these predictions using a fear con-
et al., 2019). In the study by Joos et al. (2012), participants first ditioning paradigm. Particularly, the studies by Arntz et al. (1997),
completed a conditioning phase with faces (CSs) and a loud noise and Davey and Matchett (1994), and Joos et al. (2012; described in the
scream (USs), and then they were probed three times a day for a week previous section) were inspired by the fear incubation theory. In the
to “think back to the picture, the [scream/noise] and the relationship be- study by Arntz et al. (1997), participants were asked to engage in cue-
tween them” through text messages. They found that fear ratings were induced mental imagery (i.e., “Every time when this mark is on the
higher for the contingency that was mentally rehearsed, compared to screen, you have to think of the stimulations you have just experienced
the contingency (using the other US) that was not rehearsed, but only and of how painful they were”) following a conditioning phase with
when the rehearsed US was a scream (and not the loud noise). Likewise, mild electric shocks as CS and a more intense electric shock as US. In

6
 Table 2
Overview of the included studies and their procedural details.
Reference CS type US type Type of imagery Control condition Imagery measures Outcome measure Main findings Sample size
(s) (s)
G. Mertens, et al.

Agren et al. (2017) Colored lamps Shock Imagine CS AS N/A SCRs Fear extinction & interference with fear memory 86
reconsolidation
Arntz et al. (1997) Mild electric Painful shock Imagine US NI Custom ratings SCRs Slower SCR habituation. 72
stimulation II
AS
Davey and Matchett (1994) Geometric shapes Loud noise Imagine US II Custom ratings SCRs Stronger SCRs in the imagery group compared to 40
Exp. 1 controls.
Davey and Matchett (1994) Geometric shapes Loud noise Imagine US II Custom ratings SCRs Stronger SCRs in the Imagine US group compared to 42
Exp. 2 controls.
Dibbets et al. (2012) Pictures of vehicles Picture of injured Rescript US NI QUMI SCRs Reduced return of fear with US expectancy in the 70
child II US expectancy Rescript US group compared to controls.
Dibbets et al. (2018) Pictures of kitchen Aversive video Rescript US AS Custom ratings SCRs Changed US representation in rescripting group but no 105
utilities EM intervention US expectancy between group differences.
Grégoire and Greening Gabor patches Shock Imagine CS NI Custom ratings SCR Retrieval-induced facilitated extinction for the CS that 19
(2019) Fear ratings was imagined.
Joos et al. (2012) Faces Loud tone Imagine CS-US contingency II Custom ratings US expectancy More persistent fear ratings in the imagery compared 33
Scream Fear ratings to control condition in terms of fear ratings.
Krypotos et al. (submitted) Colored squares Shock Imagine the CS, the US, and II QUMI Avoidance Avoidance responses for CS paired with imagery. 66
Exp. 1 the CS-US contingency responses Similar results for US expectancies.
Expectancy
ratings,
Fear ratings
Krypotos et al. (submitted) Colored squares Shock Imagine US II QUMI Avoidance No significant effects across all measures. 60
Exp. 2 Custom ratings responses

7
US expectancies
Fear ratings
Kunze et al. (2019) Exp. 1 Faces Aversive video Rescript US RO Custom ratings SCR No effect on reinstatement on any measure. 61
FPS
Distress rating
Kunze et al. (2019) Exp. 2 Faces Aversive video Rescript US NI Custom ratings SCR Reduced subjective CRs in the Rescript US group (but 66
Imagery inflation FPS not for other measures).
Distress rating
Valence ratings
Kunze et al. (2019) Exp. 3 Faces Aversive video Rescript US NI Custom ratings FPS Reduced differential FPS (but not other measures) in 74
RO Distress rating the Rescript US group compared to NI.
Heart rate
Landkroon et al. (2019) Colored lamps Aversive video EM intervention NI Custom ratings SCR No significant differences in fear renewal for any 75
RO FPS measure.
US expectancy
Leer, Engelhard, Altink, Tones Disgusting video EM intervention RO Custom ratings SCR EM intervention reduced conditioned fear ratings. No 63
et al. (2013) Fear ratings differences for SCR.
Leer, Engelhard, Dibbets, Geometric shapes Aversive IAPS EM intervention RO Custom ratings SCR Reduced renewal of US expectancy in EM condition. 80
et al. (2013) picture FPS No between group differences in FPS.
US expectancy
Meulders et al. (2015) Hand movement Shock Imagine CS N/A N/A FPS Generalization gradients for unpaired GSs with fear 50
Attentional bias and US expectancy ratings.
US expectancy
Fear ratings
Mueller et al. (2019) Exp. 1 Faces Stepping on Imagine US NI Defensive physiological SCR Differential conditioning for ratings and heart rate. No 45
thumbtack II responses CS ratings effects for SCR.
Heart rate
Mueller et al. (2019) Exp. 2 Faces Shock Imagine US NI Defensive physiological FPS Differential conditioning for ratings and FPS; no effect 41
II responses CS ratings for heart rate.
Heart rate
Behaviour Research and Therapy 126 (2020) 103556

(continued on next page)

G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

List of abbreviations: CS = conditioned stimulus; US = unconditioned stimulus; NI = no imagery; II = irrelevant imagery; AS = actual stimulus; RO = recall only; VI = verbal imagery; SCR = skin conductance
response; FPS = fear potentiated startle; IAPS = international affective picture system; QUMI = Questionnaire Upon Mental Imagery; VVIQ = Vividness of Visual Imagery Questionnaire; IMQ = Intrusion Memory
Sample size several conditions, participants either received actual US administra-
tions, had to engage in irrelevant pain imagery, or did not receive any
122
intervention. In a subsequent extinction phase, the US imagery group

68

48

61

66

94
demonstrated heightened SCRs compared to the actual US administra-
tion group and the no intervention group (but not compared to the

compared to the control group. No differences for US

More positive affect and less startle and fear ratings in

Conditioned intrusive mental images during a 1-week
Intrusions elicited by CS + presentations, especially

irrelevant mental imagery group). Similarly, in the studies by Davey

Extinction of conditioned SCRs due to CS imagery.

Conditioned intrusions after conditioning and one

and Matchett (1994), participants were asked to imagine the US fol-

Less differential FPS in the experimental group

lowing a conditioning phase with a loud tone (115 dB) as the US and
neutral picture as the CSs (i.e., “whenever you see the word think on the
screen you must try and imagine the loud tone presented in Stage 1 and

the positive mental imagery group.

your reactions to it as vividly as you can”). In a control condition,
participants were asked to engage in irrelevant mental imagery (i.e.,
“think about a cat meowing and reactions to it”). In a subsequent test
for female participants.

phase, participants who had to mentally rehearse the US showed

stronger SCRs to the CS + compared to participants in the control
condition, but this effect was specific for participants high in trait an-
Main findings

expectancy.
week later.

xiety. This result was confirmed in a second experiment in which the

follow-up.

effect of mental US rehearsal was obtained only for participants who

had underwent a somatic worrying induction. Overall, these results
partially support the fear incubation theory. However, no clear evi-
Outcome measure

dence has been obtained so far that the effect is specific to mental
fMRI activation

US expectancy

imagery of the US rather than unpleasant imagery generally (see Arntz

Fear ratings
Number of

Number of

Number of
Heart rate
CS ratings

et al., 1997) and the effects of the mental imagery intervention seem to
intrusions

intrusions

intrusions

dissipate quickly with subsequent unreinforced CS exposures (see

SCRs

SCRs
SCR

SCL

FPS

FPS
(s)

Davey & Matchett, 1994). These latter findings fit less well with pre-
dictions of fear incubation theory.
Physiological arousal
Imagery measures

fMRI activation
Custom ratings

Custom ratings

Custom ratings

3.3. Visual mental images as conditioned responses

PANAS

PANAS

According to the ‘warning signal hypothesis’ (Ehlers & Clark, 2000;

VVIQ
IMQ

IMQ

IMQ

Ehlers et al., 2002), intrusive memories are concerned with stimuli

(e.g., sounds, odors) that were present immediately before or during a
Control condition

CS unpaired with

CS unpaired with

CS unpaired with

traumatic event and signal impeding danger, which results in a sense of

current threat. This hypothesis indicates that intrusive memories are a
reflection of an associative learning experience (i.e., the pairing of
neutral cues and a traumatic experience) and may thus be expected to
US

US

US
AS
(s)

VI

also occur as a result of a fear conditioning procedure. So far, three

II

II

studies have investigated this hypothesis. In an innovative fear con-

Imagine attachment figure

ditioning study, Wegerer et al. (2013) induced involuntary memory of a

Positive mental visual

US. Participants were exposed to a violent video clip (US) while they
Intrusive memories

Intrusive memories

Intrusive memories

heard an auditory CS (i.e., a clock ticking or a typewriter) in the

Type of imagery

background. In a subsequent memory triggering task, participants

Imagine CS

heard either the CS+, CS-, or no CS while they listened to neutral

imagery

background soundscapes (e.g., shopping mall). Assessments using an

intrusion memory questionnaire indicated that participants reported
more, longer, and more distressing mental images (i.e., intrusions) re-
lated to the US when they were exposed to the soundscape including the
Aversive films

Aversive film

Aversive film

Questionnaire; PANAS = positive and negative affect scale.

CS + than when they were exposed to the soundscape with either the
US type

CS- or no CS.
Scream
Shock

Shock

Shock

Two recent studies (Rattel et al., 2019; Streb, Conway, & Michael,
2017) extended these findings by Wegerer et al. (2013) using a similar
paradigm. Streb et al. (2017) found that a CS (clock ticking or train
Colored squares
Neutral sounds

Neutral sounds

Neutral sounds

passing by) paired with a traumatic film tended to elicit intrusive

Facial images

memories even up to one week after the acquisition phase. Rattel et al.
CS type

(2019), using the same paradigm as Wegerer et al. (2013; partly

Tones

overlapping sample), found that women, compared to men, displayed a

higher frequency and more distressing intrusions in response to the
presentation of the CS paired with the film clips, both immediately after
Toumbelekis et al. (2018)

the acquisition phase and during an ambulatory assessment. These sex

Zbozinek et al. (2015)
Wegerer et al. (2013)
Reddan et al. (2018)
Table 2 (continued)

differences were mediated by stronger responses to the traumatic films,

Rattel et al. (2019)

Streb et al. (2017)

stronger evaluative conditioning, delayed extinction, and larger state

anxiety increases in women. These three studies indicate that a fear
Reference

conditioning procedure can install distressing and persistent mental

images (i.e., intrusive memories), particularly in women.

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G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

Fig. 2. Network graph of the articles included in this review and four central theoretical papers (i.e., Arntz, 2012; Dadds et al., 1997; Ehlers & Clark, 2000; Eysenck,
1968; 1979). Colors refer to the main research question we identified (blue: mental images as replacement for actual stimuli; green: visual mental images as
conditioned responses; red: reduction of conditioned responses through mental imagery-based interventions; yellow: mental imagery and fear inflation). Articles
(nodes) at the beginning of each arrow (edge) included the article at the end of the arrow in its reference list. (For interpretation of the references to color in this
figure legend, the reader is referred to the Web version of this article.)

3.4. Reduction of conditioned responses through mental imagery-based intervention group and an irrelevant imagery group). Similarly, in
interventions Dibbets et al. (2018), participants were exposed to a video clip in which
a woman gets visibly burned in the face during a kitchen accident. This
Several lab studies have addressed whether mental imagery can video clip (US) was paired with kitchen utensils as CSs. In the imagery
reduce conditioned fear responses. A first approach used a laboratory rescripting intervention, participants were asked to imagine that they
model of the imagery rescripting intervention (Arntz, 2012; Morina were able to help the woman and that she recovered from her burns
et al., 2017). Particularly, in a study by Dibbets, Poort, and Arntz after treatment in the hospital. This intervention was compared with an
(2012), participants saw a picture of an injured child as the US and of extinction intervention (i.e., unreinforced CS trials) and an eye-move-
vehicles as the CSs, and they were told before conditioning to imagine ment intervention (see below). All three interventions were successful
that the child got injured in an accident with one of the CSs. During the at reducing US representation ratings (i.e., the amount of details and
rescripting intervention, participants were asked to imagine that the vividness, evoked tension and averseness, and experienced negativity).
child got saved and recovered after the accident. Dibbets et al. (2012) However, the extinction intervention was the most effective of the
found that this intervention reduced return of fear after successful ex- different conditions to reduce conditioned skin conductance responses
tinction, as measured with US expectancy ratings (compared to a no- and US expectancy ratings. Finally, in a series of three studies by Kunze,

9
G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

Arntz, and Kindt (2019), participants were asked to rescript the content 4. Discussion
of a visual US (clips from the film ‘Salo’, or the 12 Days of Sodom’) used
in a prior conditioning phase in which the face of the main character The current systematic review provided an update of studies on
served as the CS. Specifically, participants were asked to imagine a mental imagery in human fear conditioning since the publication of the
more satisfying storyline for the US (e.g., image that the scene was review by Dadds et al. (1997). Based on a systematic search, 20 articles
merely a fake movie) freely (Experiment 1) or using a standardized (reporting 25 studies) were identified that focused on the role of mental
rescripting intervention (Experiments 2–3). The effects of this inter- imagery within fear conditioning. These studies were centered around
vention were compared to a condition in which participants merely had four thematic research questions: (1) Whether mental imagery can re-
to imagine the US (Experiments 1 and 3) or against an imagery inflation place the actual administration of CSs and USs; (2) Whether mental
intervention (Experiment 2). Some aspects of the results of Kunze et al. imagery can lead to conditioned fear inflation; (3) Whether CSs can
(2019) indeed indicated that the interventions could reduce the in- evoke visual mental images; and (4) Whether conditioned fear re-
tensity of the US memory and subjective distress to the CS. However, sponses can be reduced through mental imagery-based interventions.
the authors note that further steps need to be taken to make the re- For each of these questions, some confirmatory evidence has been
scripting intervention more powerful and to assess its effects against found. However, there is substantial heterogeneity in the procedures,
suitable control conditions. measures of mental imagery, and control conditions (see Table 2 and
Another approach to reduce conditioned responses using an ima- the Supplementary Materials), complicating any direct comparison
gery-based intervention makes use of a lab model of the eye movement between the studies. Furthermore, the available evidence for each of
component of EMDR therapy (Shapiro & Forrest, 2016). Particularly, in the 4 different research questions is currently based on a limited
a series of studies by Leer and colleagues (Leer, Engelhard, Altink, et al., number of available studies and for some of them relevant control
2013; Leer, Engelhard, Dibbets, & van den Hout, 2013) and Landkroon, conditions and manipulation checks are missing (see Table 2). In the
Mertens, and Engelhard (2019), participants were asked to recall the next few paragraphs, we will discuss several theoretical models,
memory of a visual US while they made lateral eye-movements after a methodological considerations, and open questions that could guide the
conditioning phase with the visual US (i.e., an unpleasant IAPS picture further development of research in this field.
or an unpleasant film clip). There is a considerable amount of research
suggesting that such an intervention can reduce the vividness and 4.1. Integration with theoretical models
emotional intensity of emotional memories (Engelhard et al., 2019; Lee
& Cuijpers, 2013), and therefore it was expected that this intervention The results of the reviewed studies validate the view that looking at
would reduce the intensity of the US memory and, consequently, reduce the mental level of analysis can yield additional insights compared to
CRs. No consistent effects were found for psychophysiological measures restricting oneself to the observable elements of the procedure. That is,
of fear, but this intervention did indeed attenuate the US memory mental images can be part of the conditioned response, and can be a
(Landkroon et al., 2019; Leer, Engelhard, Altink, et al., 2013), and re- replacement for the actual administration of the CS, US, and CS-US
duced conditioned subjective ratings (Leer, Engelhard, Altink, et al., contingencies. Furthermore, considering the potential implication of
2013) and the return of fear after a context switch (Leer, Engelhard, mental images in the incubation and preservation of fear, and its pro-
Altink, et al., 2013). However, return of fear one day later was not mising role in therapeutic interventions, we argue that mental imagery
significantly reduced in the study of Landkroon et al. (2019). So, there should be considered as an indispensable level of analysis in fear con-
is evidence that the eye-movements approach may be used to reduce ditioning research. This, however, does not imply that the goals of the
conditioned fear (assessed with subjective measures) at least tempora- behaviorists to focus on observable, and therefore verifiable, behaviors
rily, but more studies with long-term follow-up tests are needed. need to be given up. That is, the functional approach of behaviorists to
A third approach using a mental imagery intervention to reduce link elements in the environment to behavior and the cognitive ap-
conditioned fear responses was reported by Toumbelekis, Liddell, and proach of studying mental processes that mediate such behavioral ef-
Bryant (2018). Particularly, in their procedure, participants were asked fects are complementary and mutually informative (De Houwer, 2011).
to think of an attachment figure prior to a fear conditioning phase with Therefore, they can be studied simultaneously as long as researchers
colored squares as CSs and an electric shock as the US. Compared to a distinguish between the procedure and effects on the one hand (what
control condition in which participants had to think about a hypothe- needs to be explained) and the hypothesized cognitive processes (which
tical situation that would make them feel happy (only involving provide the explanation) on the other hand (De Houwer, 2011;
themselves), thinking of an attachment figure resulted in reduced dif- Hermans et al., 2018).
ferential fear potentiated startle responses (but not US expectancy rat- Speculating on the function of mental imagery in fear conditioning,
ings), and this difference between the conditions was maintained in a mental images can be seen, just as other commonly observed condi-
48h follow-up test. Hence, this study provides preliminary support for tioned fear responses, as preparatory reactions to an upcoming aversive
the idea that thinking of an attachment figure can reduce the acquisi- stimulus. That is, mentally imagining an upcoming US or an intrusive
tion of conditioned startle responses. memory of an earlier aversive event may indicate impending danger
Finally, in a study by Zbozinek et al. (2015) a mental imagery mood and help in taking appropriate action in dealing with the US. Thus,
induction was used with the aim of reducing return of fear. This hy- mental imaging may serve an important anticipatory function (as a
pothesis was based on the idea that lingering negative valence after an ‘warning signal’; Ehlers et al., 2002), just like other conditioned re-
extinction intervention facilitates the return of fear (Dirikx, Hermans, sponses (e.g., sexual arousal; salivation) have been argued to prepare
Vansteenwegen, Baeyens, & Eelen, 2004). In the intervention, partici- for upcoming USs (e.g., sexual intercourse; food intake) (see Domjan,
pants were asked to imagine positive scenarios (e.g., “It's your birthday, 2005). In fact, other commonly observed conditioned responses in the
and your partner reaches over to you with a present. You open it and feel context of fear conditioning (e.g., skin conductance responses, po-
incredibly happy”). Compared to a positive verbal training condition, tentiated startle responses, accelerated heart rate) may be seen as the
positive imagery training resulted in more positive affect, reduced ne- consequence of this anticipation of the US (Davey, 1992; Fanselow &
gative CS + evaluation, and reduced the return of fear as measured by Pennington, 2017; Lovibond, 2011). Such models with a central med-
startle responses and fear ratings. This study indicates that a mental iating role of the mental US representation are central to contemporary
imagery mood induction may be used to reduce conditioned fear re- models of classical conditioning (Hosoba, Iwanaga, & Seiwa, 2001;
sponses and counter the return of fear. Rescorla, 1988).
However, the function of mental imagery in fear conditioning may
extend beyond mere anticipation of and preparation for the US.

10
G. Mertens, et al. Behaviour Research and Therapy 126 (2020) 103556

Specifically, mental imagery is proposed to be a constructive process for mental imagery measures. Large scale initiatives are needed to provide
developing mental representations of possible future scenarios based on insights in the differences between the various control conditions for
previous (conditioning) experiences (Schacter, Addis, & Buckner, 2007; imagery and how inter-individual differences in mental imagery are
Schacter et al., 2012). This feature of mental imagery has clear evolu- related to subjective, behavioral, psychophysiological, and neural as-
tionary advantages because it allows us to prepare for possible future pects of fear conditioning.
situations beyond those previously encountered. This idea is supported Another direction for future research is to pinpoint the learning
by some of the studies included in this review. Particularly, several principles underlying the reported effects. To illustrate, some of the
studies demonstrated that mental imagery can install fear responses imagery effects could be explained by fear generalization (i.e., the
even when no physical stimuli have been directly paired (Krypotos spread-out of CRs from a CS + to similar stimuli; Dymond, Dunsmoor,
et al., 2019; Lewis et al., 2013; Mueller et al., 2019). Furthermore, Vervliet, Roche, & Hermans, 2015), second-order conditioning (i.e., the
several studies showed that mental revaluation of the US can result in conditioning of a CS through its pairing with another CS that has been
the spontaneous inflation of conditioned responses (Davey & Matchett, previously paired with the US; Davey & Arulampalam, 1982) or effects
1994; Gazendam & Kindt, 2012; Joos et al., 2012). Hence, in the ab- of verbal instructions (i.e., installation of CRs via mere verbal in-
sence of any direct experience, mental imagery can both instill and formation about CS-US contingencies; Mertens, Boddez, et al., 2018).
strengthen CRs. For example, in the study by Joos et al. (2012) in which participants
Taken together, mental imagery within fear conditioning seems to were probed to think back about the relationship between the CS and
be related to the anticipation of and preparation for the occurrence of the US, mentally rehearsing the CS may have allowed for an easier
the US, and allows us to extend conditioned responses to stimuli, si- generalization (possibly due to a better maintained representation of
tuations, and contexts that have not been previously experienced. This the CS) of learned fear from the first day to the testing session a week
fits well with theories of classical conditioning according to which later. Likewise, in the studies by Mueller et al. (2019), where partici-
conditioned responses are the result of the generation of expectations pants had to imagine an aversive image (e.g., stepping on a thumbtack)
about an upcoming US (Davey, 1992; Lovibond, 2011; Mertens, after being presented a shape and then that shape was paired with a
Boddez, et al., 2018; Reiss, 1980). A similar conclusion was recently neutral face, the observed fear responses for the face could be explained
reached by Ji et al. (2016) in their review on mental imagery: “These by second order conditioning of the face with the, now aversive, shape.
contemporary accounts view mental imagery as a core component of the These potential alternative explanations of the reported effects show
“prospective brain,” which enables the simulation of hypothetical future that plenty of work needs to be done before we reach a theoretical
events based on prior knowledge and memories of past experience for the consensus on mental imagery in fear conditioning. Further investigation
purposes of prediction and planning” (p. 703). This conclusion also fits is also needed for the prediction that specifically sensory-perceptual
nicely with Bayesian models of learning and predictive coding theory, mental imagery elicits strong emotional reactions compared to verbal
according to which individuals form predictions about the outside processing, a prediction that has been made by several researchers
world, based on their prior experiences (Bubic, von Cramon, & (Holmes & Mathews, 2010; Lang, 1979; J.; Pearson, Naselaris, Holmes,
Schubots, 2010; Kruschke, 2008) and which have recently been used to & Kosslyn, 2015). Within the fear conditioning literature on mental
develop computational models to understand the symptoms of mental imagery, this hypothesis has not received much attention. Only one
disorders (Adams, Huys, & Roiser, 2015). study has investigated this hypothesis using an appropriate control
condition (i.e., verbal imagery) (Zbozinek et al., 2015) and another
4.2. Limitations, open questions and future directions study demonstrated that verbal-based worrying (rather than mental
imagery) can lead to the strengthening of conditioned fear responses
A first main limitation of our systematic review is that only 25 (Gazendam & Kindt, 2012).
studies fitted our inclusion criteria, addressing the four different re- Another important direction for future studies is testing whether
search questions. Due to this limited number and the lack of metho- mental imagery ability is a stable inter-individual trait (Andrade et al.,
dological standardization, we restricted ourselves to a qualitative as- 2014; D. G.; Pearson et al., 2013) that predicts the development and
sessment of the available studies, rather than using a quantitative maintenance of conditioned fear or intrusions in the lab. According to
approach (e.g., using meta-analytical tools). A second limitation is that contemporary fear conditioning models, the intensity of learned fear is
we largely limited ourselves to giving a descriptive overview of these not just determined by threat expectancy but also by threat intensity.
studies. A thorough quality assessment was not possible as there are That is, a CS that signals low probability and intense threat can still
currently no generally accepted methodological standards on how to elicit strong fear (e.g., the fear that a plane will crash) (Vervliet et al.,
optimally manipulate and control for mental imagery in conditioning 2013). Perhaps individuals with high mental imagery ability develop
studies (though a lack of any control condition or mental imagery US representations that elicit more fear or could more easily imagine a
measure was noted for the reviewed studies and is indicated in Table 2). (low probability) CS-US contingency. Likewise, mental imagery ability
A third limitation is that the protocol of our review was not registered could predict the effectiveness of mental imagery interventions to re-
on a public repository (e.g., Prospero). Therefore, it is possible that our duce acquired fear. Of the reviewed studies here, only four included
conclusions are unintentionally biased. However, this risk was partly measures of trait imagery (see Table 2). Of these, only Dibbets et al.
mitigated by having the literature selection and data extraction in- (2012) included trait imagery as a factor in the statistical models. They
dependently checked. found no differences regarding effects of the imagery rescripting in-
Despite the low number of selected studies, our review shows that tervention among participants scoring ‘good’, ‘moderate’, or ‘poor’ on
for each of the four questions, tentative confirmatory evidence has been their trait mental imagery ability. Given that these are the results of a
found. The studies strongly suggest that integrating the research areas single study, the hypothesis that trait mental imagery ability matters for
of mental imagery and fear conditioning can advance our under- imagery-based interventions requires additional empirical evaluation.
standing of the etiology and treatment of anxiety-related disorders. Last but not least, a substantial minority of patients with anxiety-
Therefore, it seems critical that more research will be conducted that related disorders benefit insufficiently from exposure-based therapy
brings these fields together. Given the methodological heterogeneity of and it remains unclear whether mental imagery-based interventions can
the reviewed studies, more research will have to clarify what optimal enhance treatment effects. For instance, recent studies have found that
control conditions for mental imagery are and what measures of ima- patients who show reduced fear extinction in a fear conditioning task
gery are optimal as a manipulation check. It also remains unclear before treatment benefit less from exposure-based therapy (e.g., Geller
whether mental imagery constitutes a unitary construct, and it is dif- et al., 2019). An important area for future lab research would be to test
ficult to compare studies utilizing different control conditions and whether mental imagery based interventions promote approach

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Costa, V. D., Bradley, M. M., & Lang, P. J. (2015). From threat to safety: Instructed re-
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