1. Introduction

Over the previous two decades there has been growing scientific interest in the role that negative mental imagery may play in the onset and/or maintenance of some clinical disorders; for example, Depression, PTSD, Schizophrenia, Social Anxiety Disorder, Stroke, MS, Craving and Eating Disorders (see ^[1] for review) and its relevance for, and impact upon clinical treatment programmes; for example, imagery re-scripting in CBT (e.g. ^[2], schema focused therapy (e.g. ^[3]) and positive interpretation training (e.g. ^[4]). The scientific evidence for the role of negative mental imagery in Social Anxiety Disorder (SAD) is promising; for example, a negative mental image of the perceived self has been argued to be a key cognitive process for SAD maintenance (see ^[5] for review) and recent empirical evidence has demonstrated that SAD symptoms can be alleviated by self-imagery based interventions (e.g. ^{[6, 7, 8]}). In addition to the research on negative mental imagery, there is a small and limited body of work that has explored the impact of positive mental imagery in the context of social anxiety, in non-clinical student populations; for example, ^[9] and ^[10] have demonstrated the potential benefits of positive mental imagery for decreasing feelings of anxiety, while ^[11] and ^[6] have demonstrated its benefits for increasing self-esteem. Indeed, a recent review, ^[12] highlights the potential for positive mental imagery in social anxiety contexts, despite making recommendations for replication in clinical populations and emphasising a need for appropriate control conditions.

Particular relevance to the present study, ^[12] draws attention to the fact that little is known of the optimal way to promote positive mental imagery in SAD. Indeed, the conventional approach, based upon the methods outlined by ^[13], may be too demanding cognitively and emotionally for individuals with clinical levels of social anxiety, due to their reduced ability to recall and elaborate upon previous positive social situation (e.g. ^[14]). This is a key point since those with SAD not only have a detrimental bias to effortlessly retrieve negative images but also poor encoding ability for positive episodes. The consequence of less rich memory for past positive episodes has the consequence of problematic later recall in SAD and is precisely why interventions which are less demanding are sought. Indeed, ^[12] suggests further exploration of hypothetical, future-orientated scenarios as an alternative.

The present study therefore aims to investigate the impact of positive mental imagery in the context of social anxiety in a non-clinical student population utilising past (i.e. conventional method) and hypothetical future orientated imagery inducement procedures. To the authors knowledge this is the first study to investigate the potential efficacy of future orientated positive mental imagery in this context.

2. Methods

A between subjects experimental design was utilised, consisting of one factor (imagery inducement technique) with three levels (past, future, and no imagery). Four dependant variables were measured (social anxiety, general anxiety, image vividness and image duration).

Seventy eight young healthy undergraduate students (28 male) were recruited from UK universities and randomly allocated (using simple randomisation) to one of three study conditions (past, future and no imagery conditions) resulting in 11 Males and 15 females in the past induced imagery condition, 9 males and 17 females in the future induced imagery condition and 8 males and 18 females in the no imagery condition.

Social Anxiety was measured by the Liebowitz Social Anxiety Scale (LSAS-SR) ^[15]. The scale has been used in social phobia research for a number of years (e.g. ^{[16, 17]}). The LSAS-SR is a standardised 4 point self-report Likert scale consisting of 24 social situations, (e.g. “speaking up at a meeting”) allowing participants to rate, for each situation, their fear of anxiety and how often they would avoid that situation. It has demonstrated high levels of internal consistency as well as good convergent and construct validity (^{[17, 18, 19]})

General anxiety was measured by the State-Trait Anxiety Inventory (STAI) ^[20]. The STAI consists of 40 statements, 20 measuring state anxiety (STAI-S; e.g. “I feel upset”) and 20 measuring trait anxiety (STAI-T; “I lack self confidence”). Each statement is rated on a 4 point scale.

Two eleven-point likert scales were implemented to measure Image vividness and image quality. Participants rated how vivid the induced image was from 0 (not at all) to 10 (extremely) and the length of time the image was held from 0 (none of the time) to 10 (all of the time).

Past induced imagery condition: participants were asked to recall a memory of a social situation where they felt significantly relaxed (positive). Once each participant confirmed they had brought an image to mind they were instructed to close their eyes and imagine the image in detail. A series of questions were presented to help aid the detail of the image (e.g. How did you look? How do you feel? How did you come across to other people? What could you hear? What were your surroundings?).

Future induced imagery condition: participants were asked to imagine a future social situation where they would feel relaxed (positive).Once each participant confirmed they had brought an image to mind they were instructed to close their eyes and imagine the image in detail. A series of questions were presented to help aid the detail of the image e.g. How did you look? How do you feel? How did you come across to other people? What could you hear? What were your surroundings?).

No imagery condition: participants were asked to name 18 well known celebrity pictures. Participants received 1 point for each correct answer. Data was not analysed.

The study received ethical approval from Teesside University’s School of Social Sciences, Business and Law ethical committee. Each participant gave informed consent and after a 5 minute relaxation (sitting quietly) period, to allow the participant to compose themselves. completed the general (STAI) and social (LSAS) anxiety scales. Participants were randomly allocated to one of the three (past, future or no imagery) experimental conditions and provided with the appropriate written instructions to induce a positive mental image or complete the picture control task. In the past and future imagery conditions, participants were instructed to complete the LSAS and STAI-S whilst holding the induced image in mind. After this, participants completed the vividness and duration scales. The participants in the no imagery condition completed the celebrity picture task rather than induce a positive mental image. Participants were debriefed and thanked for their participation.

To confirm that random allocation was successful and no systematic differences were present before intervention, pre-task self-reported levels of general (STAI) and social anxiety (LSAS) was explored by three separate one-way (past X future X no imagery) ANOVAs. To test the effect of positive mental imagery on general and social anxiety, two separate one-way ANOVAs utilising post-imagery change STAI(S) and LSAS score as the dependent variable was implemented. All significant effects were further explored by post-hoc (Bonferroni) test. Finally, image vividness and image duration was explored by two separate one-way (past X future) ANOVAs.

3. Results

Means and SD of self-reported ratings of general (STAI) and social (LSAS) anxiety, pre and post positive mental image inducement, for past, future and no imagery conditions can be found in Table 1. Means and SD of self-reported ratings of image vividness and image duration can be found in Table 2.

Table 1. Means and SD of self-reported ratings of general state (STAI-S), trait (STAI-T) and social (LSAS) anxiety, pre and post positive mental image inducement, for past, future and no imagery conditions

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One way ANOVAs revealed no significant effect of imagery condition on general anxiety [STAI(T) - F(2,75)=.427, p =0.654; STAI(S)- F(2,75)=.038,p=0.963] or social anxiety [LSAS-F(2,75)=0.233,p=0.793] before imagery inducement. This confirms no systematic differences between groups prior to imagery inducement. See Table 1.

One way ANOVAs revealed a significant effect of imagery condition on general anxiety [STAI(S) - F(2,75)=11.12, p<0.01] and social anxiety [F(2,75)=7.13,p<0.01] see Table 1 and Figure 1. Post hoc (Bonferroni) analysis revealed significant differences between past imagery and no imagery conditions for general (p<0.01; Cohen’s d=1.36) and social anxiety (p=0.03; d=1.03); between future imagery and no imagery condition for general (p < 0.01; d=1.06) and social anxiety (p<0.01; d= 0.95); however, no significant difference between past imagery and future imagery conditions for general (p = .747) and social anxiety (p=0.936). See Figure 1, Panel A (general anxiety) and Panel B (social anxiety).

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Figure 1. Mean change in self reported ratings of state (STAI-S) and social anxiety (LSAS) for past, future and no-imagery conditions

One-way ANOVA revealed no significant difference between past imagery and future imagery conditions on self reported ratings of image vividness [F(1,50)=0.022, p=0.884] and image duration F(1,50)=0.631,p=0.431]. See Table 2.

Table 2. Means and SD of self-reported ratings of image vividness and image duration of past and future imagery conditions

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4. Discussion

The primary aim of the current study was to explore the potential of future orientated positive imagery in reducing social anxiety in a health population. Pictet’s ^[12] review suggests such research activities are warranted given the difficulties with conventional inducement techniques with regards to the demands placed on the individual. The results of the present study demonstrated that positive mental imagery can reduce feelings of general and social anxiety in healthy volunteers. In addition, and for the first time, the results demonstrated that positive mental imagery induced by imagining a hypothetical future scenario can reduce feelings of general and social anxiety (large effect sizes d= 1.06, 0.96) in healthy volunteers; with confirmation it is as effective as positive mental imagery induced using past events (large effect sizes d = 1.36, 1.03) from memory; leads to similar image vividness ratings and can be held for a similar period of time. These results are the first to demonstrate the effectiveness of hypothetical future orientated positive mental imagery in this context and provide evidence that such an inducement technique may be a useful method, for clinicians, when faced with individuals who cannot induce positive mental imagery from their own memory (i.e. those who suffer from social anxiety disorder); however, replication in a patient population is needed.

These results are in line with previous work demonstrating the beneficial impact of positive mental imagery on a number of psychological markers of well-being in non-clinical populations (e.g. ^{[6, 9, 10, 11]} and provide support to ^[12] request to further explore the optimal inducement technique for positive mental imagery. The processes underpinning the efficacy of positive mental imagery are not fully understood; however, the self-memory system (SMS) outlined by Conway and Pleydell-Pearce ^[21] has proved to be a useful framework. The SMS suggests that self-images, and their related autobiographical memories are responsible for the development of a working-self. Hulme et al. ^[11], using this framework, provided preliminary evidence that imagery (in particular positive imagery) may help people access a more positive working-self and thus go some way to breaking one of the vicious cycles proposed to maintain social anxiety – a negative self image and working-self. We postulate that the same underlying process may account for the effects of hypothetical future orientated positive mental imagery, as previous research has shown that both past and future imagery requires similar psychological processes (e.g. those subserved by the hippocampus) during the imagery inducement ^{[22, 23]} and it has been demonstrated that individuals can base predictions of the future on atypical past experiences that are not necessarily going to happen ^[24] leading to the belief that imagining the future increases the likelihood that the event will occur ^[25] (Carroll, 1978). In addition to this, both past and future induced images have been shown to be equitable in terms of vividness, detail and are contextually specific ^[26].

Future research should consider the limitations of this study; first, as this was a proof of concept study we decided to recruit healthy volunteers – future work should replicate these findings in a high/low social anxiety group, in a clinical population and track improvement over time. It should also be noted that our male population was under-represented. Second, the questions used to induce and improve the detail of the image may have increased the likelihood of the participant implementing an observer perspective and it has been suggested that a field perspective (open’s own eyes; e.g. ^[27]) may be more effective (see ^[12] for discussion). Third, we implemented a non-imagery based control condition, as we believe this acts as a true control; however, previous work has often used a negative and /or neutral imagery condition for comparison (e.g. ^[13]). In conclusion, this study demonstrates, for the first time, that hypothetical future orientated positive self imagery can reduce subjective feelings of general and social anxiety in healthy volunteers. This method of imagery inducement may have clinical application for those who suffer from social anxiety; however, further work is needed in clinical populations.

References

[1]	Pearson, D. G., Deeprose, C., Wallace-Hadrill, S. M., Heyes, S. B., & Holmes, E. A. Assessing mental imagery in clinical psychology: A review of imagery measures and a guiding framework. Clinical Psychology Review, 33 (1), 1-23. 2013.
	In article		View Article  PubMed
[2]	Holmes, E. A., Arntz, A., & Smucker, M. R. Imagery rescripting in cognitive behaviour therapy: Images, treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry, 38 (4), 297-305. 2007.
	In article		View Article  PubMed
[3]	Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., et al. Outpatient psychotherapy for borderline personality disorder: A randomized clinical trial of schema focused therapy versus transference focused psychotherapy. Archives of General Psychiatry, 63(6), 649-658. 2006.
	In article		View Article  PubMed
[4]	Holmes, E. A., Mathews, A., Dalgleish, T., & Mackintosh, B. Positive interpretation training: Effects of mental imagery versus verbal training on positive mood. Behavior Therapy, 37 (3), 237-247. 2006.
	In article		View Article  PubMed
[5]	Ng, A. S., Abbott, M. J., & Hunt, C. The effect of self-imagery on symptoms and processes in social anxiety: A systematic review. Clinical Psychology Review, 34 (8), 620-633. 2014.
	In article		View Article  PubMed
[6]	Stopa, L., Brown, M. A., & Hirsch, C. R. The effects of repeated imagery practice onself-concept, anxiety and performance in socially anxious participants. Journal of Experimental Psychopathology, 3(2), 223-242. 2012.
	In article		View Article
[7]	Nilsson, J., Lundh, L., & Viborg, G. Imagery rescripting of early memories in social anxiety disorder: An experimental study. Behaviour Research and Therapy, 50, 387-392. 2012.
	In article		View Article  PubMed
[8]	Lee, S. R., & Kwon, J. The efficacy of imagery rescripting (IR) for social anxiety disorder: A randomized controlled trial. Journal of Behavioural Therapy and Experimental Psychiatry, 44 (4), 351-360. 2013.
	In article		View Article  PubMed
[9]	Stopa, L., & Jenkins, A. Images of the self in social anxiety: Effects on the retrieval of autobiographical memories. Journal of Behavior Therapy and Experimental Psychiatry, 38 (4), 459-473. 2007.
	In article		View Article  PubMed
[10]	Vassilopoulos, S. Social Anxiety and the Effects of Engaging in Mental Imagery. Cognitive Therapy and Research, 29 (3), 261-277. 2005.
	In article		View Article
[11]	Hulme, N., Hirsch, C., & Stopa, L. Images of the self and self-esteem: do positive self-images improve self-esteem in social anxiety?. Cognitive behaviour therapy, 41 (2), 163-173. 2012.
	In article		View Article  PubMed
[12]	Pictet, A. Looking on the bright side in social anxiety: the potential benefit of promoting positive mental imagery. Frontiers in Human Neuroscience, 9. 2014.
	In article		View Article
[13]	Hirsch, C. R., Clark, D. M., Mathews, A., & Williams, R. Self-images play a causal role in social phobia. Behaviour Research and Therapy, 41 (8), 909-921. 2003.
	In article		View Article
[14]	Moscovitch, D. A., Gavric, D. L., Merrifield, C., Bielak, T., & Moscovitch, M. Retrieval properties of negative vs. positive mental images and autobiographical memories in social anxiety: outcomes with a new measure. Behaviour Research and Therapy, 49 (8), 505-517. 2011.
	In article		View Article  PubMed
[15]	Liebowitz, M. R. Social phobia. Modern Problems of Pharmacopsychiatry, 22, 141-173. 1987.
	In article		View Article  PubMed
[16]	Brown, E. J., Heimberg, R. G., & Juster, H. R. Social phobia subtype and avoidant personality disorder: Effect on severity of social phobia, impairment, and outcome of cognitive behavioral treatment. Behavior Therapy, 26 (3), 467-486. 1995.
	In article		View Article
[17]	Heimberg, R. G., Horner, K. J., Juster, H. R., Safren, S. A., Brown, E. J., Schneier, F. R., & Liebowitz, M. R. Psychometric properties of the Liebowitz social anxiety scale. Psychological Medicine, 29 (01), 199-212. 1999.
	In article		View Article  PubMed
[18]	Rytwinski, N. K., Fresco, D. M., Heimberg, R. G., Coles, M. E., Liebowitz, M. R., Cissell, S., ... & Hofmann, S. G. Screening for social anxiety disorder with the self‐report version of the Liebowitz Social Anxiety Scale. Depression and Anxiety, 26(1), 34-38. 2009.
	In article		View Article  PubMed
[19]	Fresco, D. M., Coles, M. E., Heimberg, R. G., Liebowitz, M. R., Hami, S., Stein, M. B., & Goetz, D. The Liebowitz Social Anxiety Scale: a comparison of the psychometric properties of self-report and clinician-administered formats. Psychological Medicine, 31 (06), 1025-1035. 2001.
	In article		View Article  PubMed
[20]	Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the state-trait anxiety scale. Consulting Psychologists. 1983.
	In article
[21]	Conway, M. A., & Pleydell-Pearce, C. W. The construction of autobiographical memories in the self-memory system. Psychological Review, 107 (2), 261. 2000.
	In article		View Article  PubMed
[22]	Schacter, D. L., Addis, D. R., & Buckner, R.. Remembering the past to imagine the future: the prospective brain. Nature Reviews Neuroscience, 8 (9), 657-661. 2007.
	In article		View Article  PubMed
[23]	Byrne, P., Becker, S., & Burgess, N. Remembering the past and imagining the future: a neural model of spatial memory and imagery. Psychological review, 114 (2), 340. 2007.
	In article		View Article  PubMed
[24]	Morewedge, C. K., Gilbert, D. T., & Wilson, T. D. The least likely of times how remembering the past biases forecasts of the future. Psychological Science, 16 (8), 626-630. 2005.
	In article		View Article  PubMed
[25]	Carroll, J. S. The effect of imagining an event on expectations for the event: An interpretation in terms of the availability heuristic. Journal of Experimental Social Psychology, 14 (1), 88-96. 1978.
	In article		View Article
[26]	Tulving, E. Episodic memory: from mind to brain. Annual review of psychology, 53 (1), 1-25. 2002.
	In article		View Article  PubMed
[27]	Wells, A., Clark, D. M., & Ahmad, S. How do I look with my minds eye: Perspective taking in social phobic imagery. Behaviour Research and Therapy, 36 (6), 631-634. 1998.
	In article		View Article