Content of Visual Mental Imagery in Mood and Anxiety Disorders: A Qualitative Systematic Literature Review

Abstract

Mental imagery is an internal representation of perceptual experiences without external sensory input. Visual mental imagery plays a recognized role in the development and maintenance of anxiety and mood disorders. In this systematic literature review, we explored the kind of visual mental imagery content, its emotional impact, and possible recurrent visual mental imagery patterns (i.e., specific theme/content type) in individuals with mood and anxiety disorders. The mood disorders included in the review were Major Depressive Disorder (MDD), bipolar disorder, suicidal behavior (attempts) and ideation, or non-suicidal injury (NSSI), as per the DSM-V. The Anxiety disorders included were post-traumatic stress disorder (PTSD) and social anxiety (SA) as per the DSM-IV and DSM-V. Electronic searches of five databases between January 2000 and April 2024 were undertaken to identify relevant publications, including qualitative, qualitative, and mixed-methods studies, with a final list of 17 studies eligible for review. The studies were synthesized using thematic synthesis. The results suggest that recurrent visual imagery content patterns across different mental health conditions include visualizing interpersonal interactions such as fighting with a spouse or another family member, suicide or self-harm-based imagery, and crossing one's boundaries by another. In addition, although individuals with anxiety and mood disorders are more prone to experience negative visual visual mental imagery, they can also experience positive visual mental imagery. In conclusion, the content of visual mental imagery can be objectively positive and negative, but ultimately, an individual's appraisal is the driving factor behind the emotional impact of visual mental imagery.

Keywords

content visual mental imagery mood disorders anxiety disorders

Introduction

Mental imagery (MI) is a sensory experience without external sensory input (Pearson et al., 2015). MI, originates from one’s autobiographical and episodic memories (Schacter et al., 2007), and can take multiple forms, such as auditory, tactile, olfactory, gustatory, and visual. Visual mental imagery, is the visual experience, often referred to as the “mind’s eye” (Holmes et al., 2016; Kosslyn, 1980) and the current focus of this review. The present review will cover the content visualized and experienced through visual visual mental imagery. MI, and visual mental imagery can present itself through four types of temporal modalities: past, present, future, and atemporal. The most common temporal directions explored by the literature are: past-oriented imagery, a type of visual mental imagery that depicts events in the past, and future/prospective visual mental imagery (PMI)-introduced by Schacter et al. (2007), as the “prospective brain,” the ability to re-align elements of episodic memory to create a future scenario or outcomes (Morina et al., 2011). This potential future scenario that can be true or fantasized. These two types of visual visual mental imagery can brought to awareness in two ways: (i) intrusively—when imagery comes to awareness without the individuals wanting it, commonly known as “flashbacks,” and (ii) voluntarily—when the individual brings imagery to awareness, either recalling or creating an image in their mind.

“Flashbacks” are unwillingly brought into awareness. These images are detailed and vivid, portraying a sense of “nowness,” (Hirsch & Holmes, 2007) and lack temporal context; usually associated with past events and is typically of an adverse nature (Wheatley et al., 2007). Intrusive visual mental imagery ranges from seconds to minutes (Pearson et al., 2013), and has been observed in a range of disorders, such as obsessive-compulsive disorder (OCD) (Speckens et al., 2007), depression (Patel et al., 2007), bipolar disorder (Holmes et al., 2011), and post-traumatic stress disorder (PTSD) (Hackmann et al., 2004). Conditions with similar etiologies have overlapping cognitions, including intrusive visual mental imagery (Holmes et al., 2016).

Although intrusive visual mental imagery is a hallmark of PTSD, there has been, in recent years, a particular focus on depression. Individuals with depressive symptoms often show higher levels of emotional distress and avoidance of negative intrusive memories than non-depressed individuals despite similar levels of self-reported intrusive memory frequency (Newby & Moulds, 2011). In addition, the intrusion of negative future oriented visual mental imagery also known as “flash-forwards”, has been associated with suicidal imagery (Holmes et al., 2007). These types of imagery have been appraised by participants both negatively and positively. For instance, individuals with depression might have the thought of throwing themselves under a train, with the same thought bringing about a sense of calm during despair (Holmes et al., 2007, 2016).

Regardless, of the pathway to awareness or temporal direction, the visual mental image can depict a multitude of different content. For instance, in the current research literature the content of PMI is explored in clinical populations, which can either be regarding individuals with different mental health conditions, such as depression (i.e., Blackwell & Holmes, 2017), and social anxiety (i.e., Homer & Deeprose, 2017), or, as part of therapeutic interventions, such as Imagery Rescripting (Yamada et al., 2018). PMI content predominantly emphasis one’s personal goals, both directly (as the primary aim of investigation) and indirectly (see Stawarczyk et al., 2013 and Liefgreen et al., 2020). These findings are to an extent consistent with the Motivational Amplifier Hypothesis (Renner et al., 2017, 2019).

Nonetheless, arguably, studies that primarily focus on personal goals alone dismiss the variety of content that individuals can experience. For instance, Baird et al. (2011) conducted a content analysis of off-task (mind-wandering) content, and their findings indicated that 53% of thoughts were related to personal goals, while 39% focused solely on the self. Alternative mind-wandering content has been outlined by Deil et al. (2023) who carried out a thematic analysis on the mind-wandering content of live music concert goers and identified participants experienced content related such as: to Nature (e.g., forest, mountains, rainstorm, jungle, water), people (e.g., friends) or Violence (e.g., battlefield and armor). Moreover, other PMI content has been outlined by Imagined interaction (II) theory by Honeycutt (2003) which states that individuals visualize future interactions with significant relational partners, including family members, friends, or co-workers. Furthermore, the conflict-linkage theory, outlines that these visualized interactions can be interpreted either as competition or cooperation, and the balance between these are biopsychosocial in nature.

Mental Imagery across Mental Health Disorders

Mental Imagery in Anxiety Disorders

The present research literature investigating visual mental imagery has given a special focus on PTSD, however, other anxiety disorders have also recently been linked to visual mental imagery such as social anxiety (SA). Individuals with PTSD suffer from “flashbacks,” a type of intrusive visual mental imagery that focuses on the recollections of the traumatic event, which usually has strong emotions and is accompanied by a sense of “nowness” (Hirsch & Holmes, 2007). These intrusive memories manifest as visual mental imagery preceded by trauma and elevated levels of distress (Iyadurai et al., 2019). The discomfort associated with intrusive visual visual mental imagery is a hub of symptomology (Brewin & Burgess, 2014). In social anxiety, visual visual mental imagery is also associated with PMI of social events (Moscovitch et al., 2013). Visualizing negative self-imagery has been shown to adversely impact self-esteem and resilience to social threats (Hulme et al., 2012). Research exploring the content of prospective visual mental imagery for different anxiety disorders is still very limited. In recent years, the clinical literature has focused more on exploring how positive and negative visual mental imagery impacts those with depression.

Mental Imagery and Depression

Major depressive disorder is a highly recurrent mental health condition, with approximately 60% of individuals relapsing after experiencing multiple depressive episodes (Richards, 2011). Depressed individuals are highly affected by intrusive imagery, which are represented by negative autobiographical memories (Newby & Moulds, 2011). These memories can display acts of rejection, social isolation, or interpersonal conflict, and are often accompanied by intense negative emotions such as sadness, anxiety, and guilt (Holmes et al., 2016).

On one hand, positive visual mental imagery can be defined as imagery with a positive meaning to the individual. For example, it can depict an individual receiving a good grade (Ivins et al., 2014), being praised at work (Yamada et al., 2018), or an instance of self-harm if it is associated with comfort (Weßlau et al., 2015). Positive visual mental imagery has been used as a motivator to achieve specific goals (Renner et al., 2017) and as a mood booster (Blackwell et al., 2013, Blackwell et al., 2025). Nevertheless, positive imagery can increase an individual's discomfort (Holmes et al., 2016). Holmes et al. (2016) highlighted that positive visual mental imagery can have a negative impact on the individual. For example, the individual may visualise the “good old days,” that is, having good memories, and positive appraisal, that may not match one's current circumstances. On the other hand, negative visual mental imagery can have a negative impact on depression symptomology, as it can also increase the negative impact on those experiencing suicidal ideation.

Mental Imagery and Suicide

A part of suicidal ideation is the visualization of the act of suicide or self-harm. This type of visual mental imagery can be appraised as either positive (i.e. comforting) or negative (i.e., distressing). Visualizing behavior increases the risk of follow-through (Holmes et al., 2007), which is linked to a “pre-feel” sensation and the feeling of nowness that encompasses visual mental imagery (Ji et al., 2016). A recent study suggested that 82% of adults who reported suicidal visual mental imagery wanted to act upon it (Schultebraucks et al., 2019).

Moreover, these images are particularly impactful because of their toxicity and ability to hijack attention as well as, their ability to promote behavioral actions (Holmes et al., 2007). Thus, there is a paradox when toxicity translates to comfort. Weßlau et al. (2015), reported that individuals with objectively negative images can have positive associations/appraisals, such as, comfort or as a perceived way out. Similar findings can also be found during bipolar suicidal ideation (Di Simplicio et al., 2016). These findings raise a question of intent. It is currently established that individuals who engage in non-suicidal self-injury (NSSI) the visualization of self-harm with no intent of dying, use it as a coping mechanism. Future research should focus on understanding whether differences in imagery can illuminate the question of intent. Nevertheless, it has been reported that those with higher frequency visual mental imagery and impulsivity are more likely to attempt suicide (Wetherall et al., 2018).

The role of the content of visual mental imagery in mood and anxiety disorders often goes unmentioned in the literature. Instead, the focus tends to be on how vivid and frequent these mental images are. However, it's crucial to understand how the actual nature of these images might affect someone's mental health. By looking into visual mental imagery content, we might understand more holistically about the mental health issues individual's face. The current study aimed to identify salient themes representing participants’ visual mental imagery content, their associated emotional valence and appraisal, and how these are presented across mood and anxiety disorders.

Method

Data Sources and Search Strategy

For the current review, five electronic databases (PubMed, ScienceDirect, Web of Science, PsycINFO, and PsycArticles) were systematically searched to identify potential articles for the review. The search was undertaken using the combinations of the following keywords: [“mental imagery” AND depression], [“mental imagery” AND anxiety], [“mental imagery” AND suicid*], [“mental imagery” AND mood], [“visual mental imagery” AND depression], [“visual mental imagery” AND anxiety], [“visual mental imagery” AND suicid*], [“visual mental imagery” AND mood], [imagination AND depression], [imagination AND anxiety], [imagination AND suicid*], and [imagination AND mood]. The terms’ visual mental imagery” and “mental imagery” were included separately, as the literature often refers to mental imagery instead of visual mental imagery. Additionally, the researchers searched for studies published between 2000 and 2020, with updates in 2023 and 2024 (there was a surge of studies that included the content of visual mental imagery). The rationale for the chosen timeframe was based on recent reviews covering topics, such as Schubert et al. (2020) and Morton and MacLeod (2023). Data collection and analysis were performed according to the PRISMA review guidelines. The quality and risk of bias used for the current review were defined according to the Mixed Method Appraisal Tool (MMAT). MMAT was chosen because of the heterogeneity of the studies.

Eligibility Criteria and Study Selection

The current review adopted, both a priori and a posteriori stands. At priori, we decided to include only studies that were (i) published in English, (ii) full-text studies, (iii) empirical studies, iv) intervention studies–but only include data before the intervention, data only at baseline, data only at baseline, and (v) case studies in which participants generated their visual visual mental imagery content without the researchers’ instructions on that content to generate, (vi) participants with anxiety and mood disorders (classified by either the DSM-IV or DSM V–as our search expands through both these versions of the classifying criteria), or history of suicidal behavior (i.e., ideation, self-injure/attempters), and (vii) focus on studies that provide descriptions of mental images that participants experience in their daily lives, rather than ratings of vividness for images generated/memories retrieved in response to cues/descriptions.

In terms of exclusion criteria, (i) studies relating to psychosis were excluded because of the nature and visual symptomology (i.e., hallucinations related to psychosis) of the conditions. In addition, (ii) studies that looked at the link between visual mental imagery concerning medical diagnosis/conditions or medical procedures (e.g., dialysis) were excluded, mainly because of their unique situation and inapplicability to the broader population, as well as neuroimaging studies. (iii) Meta-analyses or systematic reviews. Furthermore, (iv) studies that involved participants suffering from alcohol or substance abuse were also excluded because of the side effects of alcohol or substance abuse, which could interfere with the participants’ visual visual mental imagery. In addition, following other reviews covering visual mental imagery, such as Schubert et al. (2020), Lawrence et al. (2023), and (v), no unpublished studies (gray literature) were included.

A posteriori, we acknowledge the studies of Morton and MacLeod (2023) and Schubert et al. (2020). Both of these reviews investigate the effect of past- and future-oriented visual mental imagery on the individual. Schubert et al. (2020) focus on emotional valence and the magnitude of its impact on an individual's life. Morton and MacLeod (2023) argue that Schubert et al. (2020) focus primarily on valence rather than emotional impact (the strength of the effect per se). Regardless, none of these reviews focused on the content of visual mental imagery or the appraisal attached to the content. Another noteworthy review is the recent review by Lawrence et al. (2023), which covers NSSI and suicidal content. However, none of these reviews focused explicitly on both mood and anxiety disorders congruently, nor investigate the content of both past and future visual mental imagery. Our review primarily focused on the qualitative expression of the content of both past and future visual visual mental imagery, and had a range of (> 10 years).

Data Extraction & Quality Assessment of the Studies

The screening began by identifying titles that reflected the aims of the review, followed by reading the abstract, and subsequent full-text screening to identify which the select the studies met the eligibility criteria. Studies that met the eligibility criteria were coded for the following way: the study's authors and date of publication, study method and design, sample demographics (age and gender), clinical diagnoses, visual mental imagery (temporal) orientation, visual mental imagery valence and appraisals and findings–the content of visual mental imagery. Quality assessment of the included studies was performed using the MMAT scale (Hong et al., 2018), which was specifically designed to account for qualitative, quantitative, and mixed-methods studies. Two independent reviewers coded and evaluated each paper for bias during data extraction. It is important to note that some studies included control groups. If the control group was composed of participants with a clinical diagnosis of either a mood or anxiety disorder, the data were extracted and clearly labeled. However, if the control group was composed of non-clinical individuals (individuals with no clinical diagnosis), the data were not extracted due to the aim and inclusion criteria of this review.

Data Analysis

The review employed a thematic synthesis. We adhered to Braun and Clarke's (2013) six-step approach for the data analysis. Initially, the authors familiarized themselves with the qualitative findings of the included studies. The initial codes were then created based on participants’ quotes and findings describing the content of visual mental imagery. Then, from the code, themes were created. The themes were then reviewed by the primary author and the second reviewer, discrepancies were discussed, and amendments were made until the primary author and the second reviewer were agreed. The first author and second reviewer reviewed the final themes, which are now being presented below.

Results

The PRISMA flow diagram (Figure 1) displays the article selection process. The original search resulted in 1,438 studies from the following databases: ScienceDirect, PubMed, Web of Science, PsycINFO, and PsycArticles. After removing duplicates, the search yielded 1,225 records. An additional 1,213 studies did not satisfy the eligibility criteria, leaving 12 that did satisfy the eligibility criteria. A 2024 search update was carried out and we included 5 more study that fit the inclusion criteria to the current review. Thus, a final number of 17 was included for the review. The Kappa Cohen of the extracted data included in this review was of 0.96.

Figure 1.

PRISMA Diagram for the Selection Process of Included Studies.

Study Characteristics

Table 1 details the characteristics and explicit content visualized through visual mental imagery. The included studies’ publication dates range from January 2000 to April 2024. Two studies used a qualitative methodology to explore the visual visual mental imagery content in suicidality, including ideation and self-injury (Dargan et al., 2016; Nilsson et al., 2023). Three studies investigated visual mental imagery interventions in those with PTSD (Grey et al., 2002); and depression (Wheatley et al., 2007; Yamada et al., 2018). For the intervention studies on the pre-interventions was extracted, as this imagery content had little interference from researchers. Twelve studies used a mixed methods approach (Crane et al., 2012; Dobinson et al., 2020; Di Simplicio et al., 2016; Hackmann et al., 2004; Hales et al., 2011; Holmes et al., 2007; Ivins et al., 2014; M’Bailara et al., 2024; Speckens et al., 2007; Shu et al., 2020; Weßlau et al., 2016; Yamada et al., 2018). Five studies focused on depression (Crane et al., 2012; Holmes et al., 2007; Weßlau et al., 2016; Wheatley et al., 2007; and Yamada et al., 2018), two of which (Crane et al., 2012; Holmes et al., 2007), participants had a history of suicidality. Three studies focused PTSD (Ehlers et al., 2002; Grey et al., 2002; and Hackmann et al., 2004). Four studies, focused on bipolar disorder (Di Simplicio et al., 2016; Hales et al., 2011; Ivins et al., 2014; M’Bailara et al., 2024). One study focused on OCD (Speckens et al., 2007), two studies focused on social anxiety (Dobinson et al., 2020; Shu et al., 2020). One study included several anxiety conditions that fit the DSM-V criteria for an anxiety disorder (Nilsson et al., 2023)- please see Table 1.

Table 1.

Study Characteristics.

Author & Date	Study type	Sample size (N)	Gender & Age	Clinical status	Control group	Interrater MMAT: Quality score	Visual mental imagery orientation (Past, Present, Future)	Visual mental imagery valence and overall appraisal	Key Findings: Content of Imagery
Crane et al. (2012)	Mixed	N = 27	* Males: N = 8 * Females N = 19 *Mage = 28.00	One or more past episode of major depression and all were in recovery at the time of participation	No	4*	Prospective visual mental imagery (Future-oriented)	Positive and negative	Sitting in a lesson, watching myself running through the school gates, towards the cliffs, or thinking of different ways (to die by suicide)—Imagining afterwards how family would feel, seeing a picture in my mind's eye of how upset my family would be. Imagining the back of my wrist with cuts on it
Dargan et al. (2016)	Qual	N = 10	Females (n = 7) Males (n= 3) *Mage = 22.4	-General population (History with self-injury)	N/A	5*	Prospective visual mental imagery (Future-oriented)	Positive and negative	“ slipping and falling […] it's a fantasy of being incapacitated really” “ One image is one where I’ve got streaks of blood dripping down from my finger tips after I flicked it erm…and every direction I can actually recall the number of cuts there were at that point in time and where each of them are” “I’ll imagine falling off a bridge and breaking my leg” “I was doing something to my leg and I remember just lying there afterward and it felt like I was being kind of electrified down my leg and it was kind of a burning lightening sensation and that's erm an image I return to quite often […] I never got smells or tastes or sounds or anything…but I definitely imagine the sight quite vividly and also the feeling of what it would be like”
Di Simplicio et al. (2016)	Mixed	Bipolar group (n = 54), with two subgroups: 1) depressed (n = 27) 2) euthymic (n = 27) Unipolar depression (N = 26) Anxiety disorders group (N = 25) Control group (N = 27) * Total Sample (N = 132)	Bipolar depressive group (n = 27) Females (n = 17) Males (n = 10) Mage = 40.44(12.56) Bipolar euthemic subgroup (n = 27) Females (n = 17) Males (n =10) Mage = 40.41 (12.78) Unipolar depression- unipolar (N = 26) Females (n = 18) Males (n= 8 Mage = 44.31 (14.82) Anxiety disorders (N=25). Females (n = 19) Males: 6 Mage = 37.60 (15.43) Non-clinical controls Females (n = 16) Males (n = 10) Mage = 41.50 (13.00)	-Bipolar, -Unipolar depression, -anxiety disorders (per DSM-IV) -non-clinical controls	Yes	5*	Prospective visual mental imagery (Future-oriented)	Positive and negative	Suicide plan Dirty kitchen Image of a human brain Fear of an encounter with a teacher Fear of the husband taking the children away A man having an accident while cutting the bush. Being in a successful situation Having intimate relations with someone they would not normally have Praise Being in love with someone Images relating to work
Dobinson et al. (2020)	Mixed	N = 86	Females (n = 72 Males (n = 14) * Mage = 20.91	Primary Diagnosis : Social Anxiety Disorder + Comorbid diagnoses Include: Major Depressive Disorder (22.1%) Specific Phobia (19.8%) Generalised Anxiety Disorder (18.6%) Avoidant Personality Disorder (14%) —————– Other Anxiety Disorders (9.3%) *Post-Traumatic Stress Disorder (8.1%) —————- Eating Disorders (8.1%) Body Dysmorphic Disorder (3.5%).	No	4*	Prospective visual mental imagery (Future-oriented) Present	Negative	-P32: I’m intrinsically not enough, and I feel that I need to prove myself to others -P11: I perceive other people to be fine. They are confident and they don’t have the same issues with anxiety that I do. They are superior -P10:Other people are normal [and] I want to be like them. I want to be sociable, and I wish I could talk to somebody new comfortably, make friends easily. P7: It would be most probably hearing them thinking. I’d hear most probably negative opinions. I would hear “she is anti-social and weird, awkward.” “She is not intelligent enough.”
Ehlers et al. (2002)	Qual	Sample was required, from four studies. N = 154	NR	-Individuals that fit the symptom criteria for PTSD	No	4*	Past-oriented visual mental imagery	Negative	-Re-experiencing the assault and the moments prior—the attack by a motorcycle driver, then the worried face of his mother -Car crash -Resuscitation of a person -The policemen informing about the fatalities of the accident -The fall of the construction worker
Grey et al. (2002)	Qual	N = 4	Participant 1: 34-year-old male -Participant 2: 30-year-old female -Participant 3: 26-year-old female -Participant 4: 36-year-old female	-All participants were diagnosed with PTSD. -Participant 1: Motor vehicle accident victim -Participant 2: Refugee forced into hiding due to the Taliban. -Participant 3: Victim of assault -Participant 4: Sexual assault victim	No	5*	Past-oriented visual mental imagery	Pre- inter. -Negative	-Participant 1: Feeling sleepy and fear of internal injuries -Participant 2: Dead body of family members -Participant 3: Seeing the assailant -Participant 4: Inspection of own genitalia after the assault
Hackmann et al. (2004)	Mixed	N = 22	Female (n = 12) Male (n = 10) Age- Not reported	Individuals with PTSD	No	4*	Past-oriented visual mental imagery	Negative	-Headlights incoming towards the individual -Assailant standing by the bed with a knife -Accident and moments prior to it
Hales et al. (2011)	Mixed	Total N = 40 Bipolar group (N = 20) Unipolar depression (N = 20)	Bipolar group: Male (n=10) Female (n=10) (Mage = 38.7). Unipolar Depression group: Male (n =10) *Female (n = 10) Mage = 37.9	Bipolar group: -12 with bipolar I, -7 with bipolar II -1 cyclothymia Unipolar depression group: -10 with MDD -3 MDD remission -7 dysthymic disorder	Yes	4*	Prospective visual mental imagery (Future-oriented)	Negative	-Stab oneself to target a major artery or self-mutilation -Being attacked -Suicidal ideation- “walking towards a river and drowning” -Pointing a gun at oneself and making sure that the angle is correct -Self hanging from an observer's perspective -Jumping from a certain height -Overdosing
Holmes et al. (2007)	Mixed	N = 15	Female (N = 9) Male (N = 6) *Mage = 41.10	Depression and suicidality	No	5*	Prospective visual mental imagery	Positive and Negative	-Suicidal image with consequence -Dead self and funeral(including details of church) -Opportunity for suicide
Ivins et al. (2014)	Mixed	N = 52	Female to male ratio: 18:8- in both Bipolar and Unipolar Bipolar Mage = 40.58 Unipolar depression *Mage = 36.12	Bipolar depression and bipolar	No	5*	Prospective visual mental imagery (Future-oriented)	Positive	-Wanting to achieve it Wanting to win Tranquility Connecting to people
M'Bailara et al. (2024)	Mixed	N = 42	*Male (n = 11) Female (n=31)	Participants had Bipolar I and Bipolar II	No	4*	Past Present *Prospective visual mental imagery (Future-oriented)	Positive and Negative	Depression Death (i.e., mourning, imminent death, suicidal ideation, suicide attempt), self-depreciation (i.e., social decline, feeling of uselessness, interpersonal difficulties), violence (i.e., moral humiliation, physical abuse, injury), darkness (i.e., black, gray, fog, chaotic landscapes), worry (i.e., anxiety of, disaster situation) social distancing (i.e., loneliness) Hypomania: Ego- inflation grandiosity (i.e., grandiosity, expansiveness, omnipotence, elation, challenge, social transgression), idealized projects, stunning landscapes (i.e., flowered landscape, sunny landscape) objectification of others. Euthymia: realistic project planning (i.e., vacation, sport, work, hobbies), carrying out daily activities, contemplation of natural landscapes (i.e., aquatic, marine, sunny, mountainous), personal development (i.e., self-affirmation self-esteem, self-confidence, sociability, success) *interactions with others (i.e., family sharing, conjugal sharing, love affair, attachment, conflict).
Nilsson et al. (2023)	Qual	N = 8	Males (n = 3) Females (n = 5)	Acute Suicidal Episode + Anxiety Disorder Diagnosis + Comorbid with: Emotionally unstable personality disorder ADHD/ADD Bipolar disorder II Recurrent depression	No	*4	Prospective visual mental imagery (Future-oriented)	Positive and Negative	Themes: Suicide-approaching, Sub-themes: Imagery Flashforwards clarified the suicidal solution Themes: Suicide preventive imagery Sub-themes: Death-alienating Images
Speckens et al. (2007)	Mixed	N = 47	Females: (n = 31) Males: (n = 16) *Mage = 35.7	OCD	No	4*	Past-Oriented visual mental imagery	Negative	Interpersonal conflict: -Image of a mother screaming and hitting the participants -Image of mother screaming and insulting the participants -Being publicly humiliated -Parental domestic abuse
Suh et al. (2020)	Mixed	N = 64	Females (n = 41) Males ( n = 23) Mage = 27.00 (7.42)	Social Anxiety (SA)	No	4*	Future and Present	Negative	‘staring eyes” People around me are turning their heads to stare at me’ ‘I look like a fool. Acting hastily in tough situations. Afraid of people noticing’
Weßlau et al. (2016)	Mixed	N = 34 Depressed group (n = 17) Controls (n = 17)	Control group: Female (n = 13) Males (n = 4) Mage (n = 36) Depression Female: (n=14) Male (n= 3) Mage = 35.8	Depression	Yes	4*	Prospective visual mental imagery (Future-oriented)	Negative	-Interpersonal problems Injury, illness, or death to oneself Injury, illness, or death to others -Assault or threat of assault to oneself -Miscellaneous
Wheatley et al. (2007)	Qual	Case study 1 *Case study 2	Case study 1: Female: 30 years old *Case study 2: Female: 54 years old	Individuals were diagnosed with depression. Case 1: Depression episodes Case 2: -Recurrent depression throughout adult life. -Childhood sexual abuse -Adult domestic violence in 20 s and 30s	No	4*	Prospective visual mental imagery (Future-oriented)	Pre -inter: Negative	Case 1: Interpersonal issues—confrontation with doctor: “I was being punished by the doctor for having had three terminations” Interpersonal issues- Memory intrusion: “[…] the age of 10 she was bullied and pushed down a flight of stairs by a group of older girls. “she was aged 6 on a miserable holiday abroad with her recently divorced father when he placed her on the back of a donkey-“[…] feeling terrified and screaming until her father took her off the donkey and subsequently scolded her for having made such a fuss, calling her a stupid little girl.” Case 2: The traumatic event: sexual abuse: “[…] abuser coming up the stairs towards her.” “[…] able to fight off the sexual advances of an uncle when she was 15.”- “[…] being violently beaten by her abusive ex-husband.”
Yamada et al. (2018)	Mixed method	N = 19 participants -All participants fit the diagnostic criteria of Major Depressive Disorder -Other comorbid diagnosis -Social anxiety disorder (n = 3) -Panic disorder (n = 2) -Bulimia nervosa (n = 1) -Generalised anxiety disorder (n = 1)	Female (n = 11) Male (n = 8) Mage = 38.4	Major Depressive Disorder	No	4*	Prospective visual mental imagery (Future Oriented)	Pre-inter: Negative	Images portraying interpersonal negative interactions with family members “My mother-in-law's angry face looks like a demon. Her eyes become a golden color. She is screaming and about to attack me.” “Strong women, such as my grandmother and aunt, talk me down. I cannot talk back to them. Other weak women, including my mother, do not help me. I put on a fake smile in front of them.” Images portraying interpersonal negative interactions in a work environment: The president of my company tells me, with a laugh, that I cannot work anywhere. When I am not with my co-workers, they backbite me (speak ill of me) in the office. “Although my co-workers in the hospital can successfully perform physical therapy for a patient in front of students, I cannot perform well as a therapist.” -When I did the same failure at my desk in the office, I did not know what to do. People are watching me, but do not help me. People look away from me, when my boss accused me of being sarcastic at the office, I am working alone at a laboratory bench. Images portraying social exclusion At a social gathering party of twenty people, I am alone in the corner of the pub restaurant. People carry on a conversation, but I do not speak much. People around me are enemies and do not support me. They look friendly, but only in a superficial way. Images portraying social exclusion. I am drifting in a dark place and cannot see anything. - I am sick in bed and see the ceiling in the dark.

Note: MAAT Quality Rating (Qualitative and Quantitative): 5* = 100% quality criteria met, 4 * = 80% quality criteria met, 3 * = 60% quality criteria met, 2 * = 40% quality criteria met, 1 * = 20% quality criteria met. NR = Not Reported. Pre-inter = Pre-intervention.

Table 2.

Themes and Sub-Themes.

Themes	Subthemes	Visual mental imagery orientation	Associated conditions and studies	Quotes on content (incl. appraisals and valence)	Examples of associated appraisals and emotional valence
Interactions and reactions of self and others	Positive Social Interactions and their Appraisals	Past-oriented imagery: Bipolar: Ivins et al. (2014) Future-oriented imagery: Di Simplicio et al. (2016) Hales et al. (2011) M’Bailara et al. (2024)	Bipolar disorder: Di Simplicio et al. (2016) Hales et al. (2011) M’Bailara et al. (2024) Ivins et al. (2014)	“Receiving my assignment, I’m told it was outstanding. Reading it to the group, who congratulate me” Ivins et al. (2014) p. 237.	Bipolar : Being successful Being Accepted Being Appreciated
Interactions and reactions of self and others	Negative Social Interactions and their Appraisal.	Past-oriented imagery OCD- Speckens et al. (2007) Depression: Wheatley et al. (2007) Bipolar- Di Simplicio et al. (2016) M’Bailara et al. (2024) Future-oreiented Imagery SA: Shu et al. (2020) Depression: Yamada et al. (2018)	Bipolar disorder: Di Simplicio et al. (2016) M’Bailara et al. (2024) Depression: Wheatley et al. (2007) Yamada et al. (2018) Shu et al. (2020) OCD: Speckens et al. (2007)	“Husband's taken the children away. Seeing children with my husband, told to pack their bags and get in the car. They’re confused, they’re packing, doing what dad says. He's packing as well. I can see myself upset in the image” Di Simplicio et al. (2016), p. 678.	Bipolar: Being neglected Being humiliated Being abandoned Depression: Being lonely Being socially rejected Not being successful. SA: Negative evalution by others Being embarrased. OCD: Not good enough, Being unclean
Paradoxical appraisal and emotional valence of self-harm visual mental imagery	Positive interpretations of comfort and escape:	Future-oriented imagery	Suicide behaviour/ideation in the general population Crane et al. (2012) Suicidality in Depression Holmes et al. (2007) Suicidality in bipolar population Hales et al. (2011)	Thinking of picking up a gun and blowing my brains out (Total escape. The easiest way to die. A way of being in control when you’re out of control)- p. 656, Hales et al. (2011) In a deep wood, little chance of being found, fully leaved, summery dense, daytime dusky, see myself climbing the tree, tying rope to a branch above, putting the noose over my head and tightening it. (Brilliant. Peace and an end to suffering-sense of closure, not having to fight to be alive)- p. 65; Crane et al., 2012)	It is an escape (a way out) Pain will be over Achieving freedom Being in control
	Self-punitive interpretations or discomfort with one's own suicidal imagery.	Future-oriented imagery	Suicidality in Depression Holmes et al. (2007) Major depression disorder Yamada et al. (2018) Suicidality in bipolar population Hales et al. (2011) Suicidality in population with an anxiety disorder with other comorbid disorder Nilsson et al. (2023)	Cutting : Seeing myself from outside in bed, slitting wrists with a penknife (Being ashamed of myself. Life as painfully dull)” (Holmes et al., 2007, p. 430) Hanging: “Hanging rope for suicide is chasing me” (Loneliness)- Yamada et al., 2018, p. 35 Jumping: “Being on a platform, trowing myself in front of a train” (Holmes et al., 2007)	Loneliness Being ashamed Self-hatred (I deserve it) Worthless Frightful Helpless
Crossing one's boundaries.		Past-oriented imagery: OCD Speckens et al. (2007) PTSD: Hackmann et al. (2004): Ehlers et al. (2002) Grey et al. (2002) Depression: Wheatley et al. (2007) Prospective visual mental imagery (Future-oriented imagery): Bipolar: Di Simplicio et al. (2016) M’Bailara et al. (2024) Depression: Yamada et al. (2018)	OCD: Speckens et al. (2007) PTSD: Hackmann et al. (2004) Grey et al. (2002) Depression: Wheatley et al. (2007) Yamada et al. (2018) Bipolar M’Bailara et al. (2024)	“In the second memory she was aged 6 on a miserable holiday abroad with her recently divorced father when he placed her on the back of a donkey—she recalled feeling terrified and screaming until her father took her off the donkey and subsequently scolded her for having made such a fuss, calling her a stupid little girl.” (Wheatley et al., 2007, p. 376). “…experienced a particular look on the face of his assailant. When he had seen this expression during the assault, he had realized that nobody was going to help him and thought he would never see his wife again.”(p. 236, Hackmann et al., 2004).	Feelings of powerlessness. Feeling worthless Being bad It's my fault (Blame)

Registration

The current review has PROSPERO registration (CRD42022382885).

Thematic Synthesis

The current thematic analysis focused on themes representing visual mental imagery content across different mood and anxiety disorders. Table 2 outlines the themes and subthemes regarding visual mental imagery content as well as, the associated emotional valence and appraisal. Three major themes were identified for these disorders. Interactions and Reactions between the self and others: This theme the mental images in which the participant highlights an interaction with another person. Paradoxical appraisal and emotional valence of self harm mental imagery: This theme outlines the images that portray acts of self-harm or self-mutilation. The third theme was Crossing one's boundaries. This theme outlines the mental images that portray the individual as the victim of a crime committed by a perpetrator.

Theme 1: Interactions and Reactions Between the Self and Others

This theme highlighted mental images, that captured interactions between the individual and others in different settings. These settings could be both in the workplace or outside it. This theme has been observed in studies investigating visual mental imagery in bipolar disorder (Di Simplicio et al., 2016; Ivins et al., 2014; M’Bailara et al. 2024), compulsive–obsessive disorder (Speckens et al., 2007), depression (Weßlau et al., 2016; Wheatley et al., 2007; Yamada et al., 2018), and social anxiety (Dobinson et al., 2020; Shu et al., 2020) This theme has two sub-themes: Positive interactions and their appraisal, which highlights positive interactions and are characterized by the participants’ as having positive emotional valence and appraisal, and Negative interactions and their appraisals, which highlights negative interactions and are also characterized by the participants’ as having negative emotional valence and appraisal.

Sub-Theme-Positive Social Interactions and Their Appraisals

Participants described positive interactions as having positive emotional valence and appraisals (Di Simplicio et al., 2016; Hackmann et al., 2004; Ivins et al., 2014; M’Bailara et al., 2024). Studies investigating bipolar disorder during “positive mood” identified positive depicting visual mental imagery (Di Simplicio et al., 2016; Ivins et al., 2014; M’Bailara et al., 2024). These interactions include being praised for a well-done job or being successful in the eyes of others. Participants reported:

“Me in a very successful situation, written a brilliant book, receiving accolades. Critical acclaim in a paper. Image of me receiving award “He's so insightful” receiving it in front of friends and family” (p. 678; Di Simplicio et al., 2016).

In some cases (Ivins et al., 2014), participants highlighted the presence of others in their positive visual mental imagery as a vessel for praise and success, and appraised it as feeling appreciated and understood, as that is the source of positive emotional valence. Social interactions can exemplify the following.

“Superb sex with someone utterly untouchable. See understanding and conversation and

absolute everything being tuned in with each other. Huge praise coming your way,

acceptance and appreciation. Somebody being as infatuated with you as you are them.

Seeing a home and a setting where it is all going to happen, stuff gathered for you

because everything is going to be possible” (participant in “high mood”, Di Simplicio et al., 2016, p. 678)

Similarly, the presence of others as a source of praise has also been seen in mental images depicting professional achievements, such as:

“Private viewing of my sculpture show in New York. People talking, a happy atmosphere” (P9, BDII, p. 237; Ivins et al., 2014) or “Receiving my assignment, I’m told it was outstanding. Reading it to the group, who congratulate me” (P6, BD-I; p. 237; Ivins et al., 2014).

Another type of reported positive interaction by the participants was spending time with those closest to them. These included family and friends. For instance, “I see myself planning outings, like hiking or biking for my girlfriend and I or my daughter and I. (participant in the euthymic state; p. 185; M’Bailara et al., 2024). Similarly, “I see myself and my girlfriend diving, underwater, it's very relaxing” (participant in the euthymic state; p. 185; M'Bailara et al., 2024). Unlike the above, when relating positive content with family, several participants did not appraise it as being successful. Rather, being happy “Memory of standing on a street with my husband behind me, feeling his hand on my shoulder (this is when I was the happiest)” (participant with BD-II; p., 237; Ivins et al., 2014)- Similar content “Christmas Eve with my husband, Christmas Day with my family: how I wanted the day to go” (participant with BD-I; p., 237; Ivins et al., 2014).

Sub-Themes- Negative Social Interactions, and Their Appraisals

Participants described negative interactions as having negative emotional valence and appraisals. “Negative interactions” were reported across participants with bipolar disorder (Di Simplicio et al., 2016; M’Bailara et al., 2024), compulsive–obsessive disorder (Speckens et al., 2007), depression (Wheatley et al., 2007; Yamada et al., 2018), and social anxiety (Dobinson et al., 2020; Shu et al., 2020). These negative interactions have been reported to occur in the workplace, between either peers or authority figures (with at same element of humiliation) for instance: “The president of my company tells me, with a laugh, that I cannot work anywhere.” (p. 354; Yamada et al., 2018); or similarly:

Paranoid fear of future—teacher reprimanding me for not working. Expectation or need for punishment. Me alone in a classroom, teacher shouting, aggressive gestures, fingers pointing. Me sitting down then standing up. Height difference, I am being looked down upon physically and metaphorically (p. 678; Di Simplicio et al., 2016)

Content relating to negative interpersonal interactions included those in the participants’ personal life, “My mother-in-law's angry face looks like a demon. Her eyes become a golden color. She is screaming and about to attack me.” (Yamada et al., 2018, p. 354), or just meeting someone new for the first time (and being potentially rejected): “People seem to laugh at me and say negative things about me behind my back” (Shu et al., 2020, p. 179). Similarly social exclusion was also reported for example: “The children of my husband and his ex-wife say nothing to me, even when I give them handmade gifts at my mother-in-law's house.” (p. 355; Yamada et al., 2018)

Theme 2: The Paradoxical Appraisal and Emotional Valence of Self-Harm Mental Imagery

This theme outlines the participants visual mental imagery content relating to suicidality. These included, the act depicting self-injury and/or ideation. Participants reported visualising, overdosing hanging, car swerving, self-cutting, and jumping as a way in which they would approach suicide. This theme has been depicted in Crane et al., 2012; Dargan et al., 2016; Hales et al., 2011; Holmes et al., 2007; Holaday & Brausch, 2015; Nilsson et al., 2023; Yamada et al., 2018. This theme has two sub-themes: “interpretations of comfort and escape”. Representing positive evaluations of the suicide-based imagery content. On the other hand, the second, sub-theme: “The interpretations of guilt and hopelessness”, outlines negative interpretations and emotions linked to the visual mental imagery content. These included feeling ashamed, guilty, hopeless. Such images were appraised negatively, for instance as self-loathe (“I deserved to die”).

Sub-Theme: Positive Interpretations of Comfort and escape

The present sub theme is represented in participants with depression, with suicidality history (Crane et al., 2012; Holmes et al., 2007), and in participants with bipolar disorder (Hales et al., 2011). This sub-theme outlines, the positive appraisals experienced by participants in connection to suicide related visual mental imagery, content specifically to a form of self-injury or method to die by suicide. For instance, some participants visualized cutting: “mental image of where on my thigh I would have to stand myself to maximize the chances of hitting me femoral artery and bleeding to death” (Hales et al., 2011, BD-II, p. 656), these images are appraised by participant as “An escape route, a way out” (Hales et al., 2011, P9-BD-II, p. 656)

Similarly, the escape appraisal have also been associated visual mental imagery content depicting jumping, either off a cliff, exemplified as: “jumping from a cliff” (Holmes et al., 2007, p. 429), or jumping in front of a train:

It's a local railway station, a little station in X, not many people there, it's windy and cold. I wait there all day contemplating everything, I know at some point that day I am going to do it [jump]. … . (Crane et al., 2012, p. 63)

The appraisals, connected to the mental images of jumping, have been appraised by participants as an escape from “hell on earth”, (Holmes et al., 2007, p. 429). Additionally, at time the appraisal of escape is reported simultaneously, with “being done”. Additionally, the positive feeling of relief, was often been reported by participants: “Felt very relieved—noise & busyness stressed me out, …-it was comforting because noise of road was less & slowed down” (Crane et al., 2012).

Furthermore, the feeling of calm and the appraisal of comfort, as well as the positive emotional valence, has been reported as “ Calming because I know it's nearly all over.” (Crane et al., 2012, p. 63)” or an escape from a specific situation: “hope that it will end mine and my family's pain.” (Hales et al., 2011, p. 2-BD-II, p. 656). Appraisals such as those also been linked to visual mental imagery depicting hanging: such as: “I imagined hanging myself from a tree on the path I regularly take to the shops” (Hales et al., 2011, p. 2-BD-II, p. 656); or: “In a deep wood, little chance of being found, fully leaved, summery dense, daytime dusky, see myself climbing the tree, trying to rope to a branch above, putting the news over my head and tightening” (Crane et al., 2012, Male- previous suicide attempt, p. 65). Relatedly, to appraisals of escaping, and “being a solution,” has been reported by some participants relating to mental imagery content depicting either overdosing (Hales et al., 2011), “imagining pills altogether, how to get more pills”, car swerving “deliberately crashing my car in a specific place” (Holmes et al., 2007) or self-shutting with a firearm “Sticking a gun to my head and finding the right place of my brain to hit so the first shot would kill me” (Hales et al., 2011, P-7 BD-II, p. 656).Is worth noting, that some participants, interpreted these mental images the images as perpetuative to a carry out an attempt “The image motivated me to move it into reality” (Hales et al., 2011):

… I am alone at home a few days after an overdose of Warfarin, and I am waiting. … I add that I cut myself in the arm. Blood begins to flow, and I bleed to death, that is a more volatile image… I feel numb. It is as if feelings disappear. Maybe a little calm, no panic, not so scared. I must disconnect to be able to do it… It was the only possible way to have an end to the suffering… It made me practically obtain what is needed to kill myself, made me go to the pharmacy to get tablets, to write down login information, passwords for p.s… Then I made a suicide attempt by overdosing. (Nilsson et al., 2023, p. 7)

Sub-Theme: Self-Punitive Interpretations or Discomfort with One's own Suicidal Imagery

The sub-theme outlines self-punitive interpretations and emotions linked to one's visual mental imagery depicting suicidality, and it was represented by those diagnosed with (I) bipolar disorder (Hales et al., 2011), (II) depression (Yamada et al., 2018), (III) suicidality with a history of depression (Crane et al., 2012; Holmes et al., 2007), and (IV) in those with anxiety disorders with comorbid disorders during acute suicidal episodes (Nilsson et al., 2023).

Such images, include methods of self-injury or potential suicide attempts, which include hanging, jumping of a certain height (like a cliff or building) or front of train, car swerving or crashing, and cutting oneself. Alongside these images, participants report negative interpretations of self-loathe (“I deserved to die”) or self-punishment “punishing myself”, as well as emotions and feelings of such as, shamed, loneliness, guilt, powerlessness and hopeless. For example:

“My whole life comes… like a fast movie… It comes like a flash in one second. All the people I have disappointed and who have failed me. I see everything negative…no light… pain within me, in my soul, that much pain I could hardly breath or talk… A lot of anxiety…shame… It's a lot of pain…in the image…I can’t control anything, not even my own thoughts. The thoughts control me… I’m totally powerless” (Nilsson et al., 2023, p. 10)

Moreover, fear has been linked with realizing the magnitude and terminal nature of suicide; as well as the effect that it had or can have on other people. For example, “Scene of my brother's suicide including his trainers (I do not want to go there, I hope I do not get that bad I can do something like that)” another example of this was:

I see the process in images in front of me, … myself climbing up the crane… It is dark,cold, and windy. I imagine how it is for real…I get dizzy…I imagine what it looks like and how it feels physically and the actual doing. Then I imagine emotionally, how it will feel to stand there and make the leap. Then what I will look like when I have landed in the asphalt…What is it that I leave behind, that someone will sweep up? I become total mash, lying on the ground with cracked head…I just want to have an end to my suffering. I don’t want to expose those I like… to something… difficult.” (Nilsson et al., 2023, p. 12).

Theme 3: The Crossing of One's Boundaries

This theme captures the mental images of being assaulted or abused by another person. Participants reported visualizing being attacked by a perpetrator. This image content has been highlighted in PTSD (Ehlers et al., 2002; Grey et al., 2002; Hackmann et al., 2004), bipolar disorder (Hales et al., 2011); and suicidality in those with depression (Wheatley et al., 2007). Participants reported physical assults these assaults could be depicted in past-oriented imagery, as experienced by those with depression and PTSD, but these could also be experienced as PMI in those with depression, and SA Regarding the PMI, some participants report visualizing the aftermath of the encounter with the pepetrator as: “Being in trouble with criminals. Being beaten up, tortured. (Hales et al., 2011).” As well as the impact of the attack on themselves will have upon others:

“a patient reexperienced a particular look on the face of his assailant. When he had seen this expression during the assault, he had realized that nobody was going to help him and thought he would never see his wife again (Hackmann et al., 2004, p. 236).

Additionally, some participants visualize an image of their parents being psychological/ verbally abusive towards them: One patient for example had images of her mother screaming at her that she was useless and that she should never been born. …A female patient reported recurrent images … being part of a memory of her dad putting her head in her dinner”. (Speckens et al., 2007, p. 417). Similarly, another participant reports:

The first memory described how at the age of 10 she was bullied and pushed down a flight of stairs by a group of older girls. In the second memory she was six on … holiday abroad with her … father when he placed her on a back of a donkey-she recalled feeling terrified and screaming until her father took her off the donkey and subsequently scolded her for having made such a fuzz and calling her a stupid little girl” (participant with depression, Wheatley et al., 2007, p. 376).

Discussion

In the current review we carried out a thematic synthesis on visual mental imagery, content with its, emotional valence, and appraisal across mood and anxiety disorders. Three major themes emerged from the present data: 1) “Interactions and Reactions Between the Self and Others”: this theme outlines the mental images in which the participant highlights an interaction with another person. 2) “Paradoxical appraisal and emotional valence of self-harm visual mental imagery”: this theme indicates opposing interpretations of visual mental imagery depicting suicide or self-harm depicting. The third theme was Crossing one's boundaries. This theme outlines the visual mental images that portray the individual as the victim of physical or psychological abuse. Even though our findings and conclusions based on the studies that we have collected and synthesized, we acknowledge that not everyone who has a diagnosis of these conditions will experience visual mental imagery; in other words, experiencing visual mental imagery is not a ubiquitous feature of human experience.

The current review found that visual mental imagery content relating to interpersonal social interactions could be appraised as either positive or negative. As well as being present in both future and past-oriented visual mental imagery. In the present review, positive future-oriented visual mental imagery about social interactions was found in only bipolar disorder. These included being praised by others on professional setting or outcomes (i.e., Ivins et al., 2014), being accepted by another specific person (Di Simplicio et al., 2016; M’Bailara et al., 2024) or group (Ivins et al., 2014). These findings are consistent with the conclusions by Ng et al. (2016), as the authors outlined that those with bipolar disorder visualize visual mental imagery content in which other individuals are present, in terms of grandiosity. Nonetheless, in the wider literature, similar positive visual mental imagery content can also be found in those with depression. However, unlike with bipolar disorder, much of the literature has focused on the positive content of visual mental imagery as a therapeutic outcome, rather than a natural occurrence (i.e., Blackwell & Holmes, 2017; Yamada et al., 2018). For instance, after a cognitive modification intervention, participants reported having images about being praised and respected at work.

Negative social interaction content was found in both past-oriented and future-oriented visual mental imagery, across different mood and anxiety disorders. For instance, those with depression and social anxiety have reported experiencing visual mental imagery content relating to social rejection (i.e Speckens et al., 2007; Yamada et al., 2018). These findings have been consistent with previous research such as Hirsch and Holmes (2007) who have highlighted that individual with social anxiety tend to experience mental images of giving a speech in front of people and feeling embarrassed, mocked, and turning bright red. All of which is derived from the individuals’ fears of rejection (Moscovitch et al., 2013). Similarly, individuals with depression have also reported experiencing visual mental imagery content depicting social rejection, and/or social isolation at both work and home settings (Holmes et al., 2016; Yamada et al., 2018).

The current findings are consistent, with the Imagined Interaction (II) Theory by Honeycutt (2003), who argues that individuals visualize interpersonal interactions for a number of reasons, such as self-introspection or emotional catharsis. However, the current review suggests that the findings are only consistent with Honeycutt's theory on the grounds that both the review and theory outline that interactions with others are present when individuals visualize the future. An example of this is the individuals tendency to visualize other individuals with whom they have a prominent relationship with, such as: family members, partners, co-workers, and friends. As an extension to the II theory, Honeycutt also proposed the Conflict-link Theory, which outlines that individuals’ interactions are a balance between conflict and competition. Honeycutt's Conflict-link Theory was observed in the present review, particularly in the visual mental imagery content surrounding negative interactions between family members and co-workers (Yamada et al., 2018). In the current review, Yamada et al. (2018), participants often reported visual mental imagery content that highlighted a sense of conflict (i.e., making fun of the participants) or a comparison (i.e., between the job performance of the participants and their colleagues or peers).

The current review corroborates the Van Berg's statement “the content of emotional visual mental imagery is in principle complex as it depends highly on personally associated appraisals” (Van Den Berg et al., 2023). We found that similar content types can be appraised vastly differently. For instance, those who either has a previous suicide attempt or experience suicidal ideation highlight paradoxical appraisals surrounding themes related to suicide or self-harm; in which participants reported either having positive or negative perceptions. Positive appraisals were found to be accompanied by positive feelings of being comforted or being relieved. These feelings were often accompanied by the interpretation (appraisal) of suicide being an escape, suicide being interpreted as a way out (“being done with” a situation in which participants found themselves in). Negative appraisals, on the other hand, came with feelings of shame, guilt, and horror. These feelings were then matched with self-loading (the participant deserves to die) or being hopeless about a situation (it will end the suffering). The paradox approach to suicidal visual mental imagery content has been supported by the wider literature. For instance: Lawrence et al. (2023), and Weßlau et al. (2015) have emphasized the same on the paradoxical appraisals surrounding suicidal imagery. Furthermore, Owen et al. (2017) highlighted that suicidal ideation can be either protective, meaning, that it can discourage the individual from acting on the ideation, or precipitative, meaning, that it can encourage the individual to act on the ideation.

The current review also highlights visual mental imagery content in which the boundaries of the participants were crossed. These included being attacked (both sexually and non-sexually) or being either psychologically or physically abused. This content type has been seen across different psychiatric disorders, such as PTSD, OCD and depression, which is consistent with previous literature (Hackmann et al., 2004). Finally, it is noteworthy to mention that our findings and conclusions based on the studies reviewed and synthesized, also supported the idea that not everyone who has a diagnosis of these conditions will experience visual mental imagery; in other words, experiencing visual mental imagery is not a ubiquitous feature of human experience.

Strengths and Limitations

Overall, the current review has strengths and limitations. One strength of the current review is the focus on the content of past and future-oriented imagery across mood and anxiety disorders. In addition, the current review aimed to explore self-generated visual mental imagery, with little or no involvement of the researchers or clinicians. Furthermore, to the best of our knowledge, this was so far the only review investigating content of visual mental imagery throughout a 20-year length period.

We acknowledge that this review has limitations regarding research methodology and scope. The current review focused on the visual mental imagery term and did not include adjacent terms such as mind wandering. By focusing on visual mental imagery alone, it has potentially limited the results of the current review. The scope of the current review was quite broad; thus, it included studies with a variety of aims, methodologies, and extended different sample sizes. Consequently, the heterogeneity of the studies presented a significant challenge in the thematic synthesis. One notable heterogeneity among the studies was the diverse data collection methods employed in the included intervention and experimental studies.

In the intervention studies, due to the scope of the current review, we excluded the content of visual mental imagery post-intervention. This exclusion was necessary to avoid including the newly formed visual mental imagery content, created with the assistance of a researcher or clinician. Regardless of intervention, and empirical (experimental) studies employed various data gathering methods, including structured clinical interviews, visual mental imagery interviews (a semi-structured interview type) or other semi-structured interview types, or therapeutic exercises/interventions.

The extraction of data from these diverse interview types and interactions between researchers and participants presented a notable challenge. Some data included appraisals, particularly in studies that utilized the visual mental imagery interview. Conversely, studies that did not employ the visual mental imagery interview occasionally omitted the appraisal information. Consequently, the present review was unable to report, at times, on certain elements, such as appraisals, as they were not included in the original studies. Even though, not all information could be extracted from every study, all the included studies presented, in one format or the other, the content of visual mental imagery, and we do believe that the presented content in this review is representative.

Conclusion

In conclusion, the current review highlighted a broad variety of visual mental imagery content observed in individuals with both mood and anxiety disorders— such as interpersonal relationships, visual mental imagery depicting suicidality, and imagery depicting crossing one's boundaries. The visual mental imagery content in both groups (mood and anxiety disorders) can include both past-oriented and future-oriented visual mental imagery. Finally, our findings suggested that to have a holistic understanding of mental image content and its potential effect on the individual, it is key to understand the appraisal attached to the corresponding visual mental imagery content.

Footnotes

ORCID iDs

Catarina Gouveia Gaglianone

Hugo Senra

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data sharing is not applicable to this review article as no new data were created or analyzed in this study.

Author Biographies

Catarina Gouveia Gaglianone, PhD, is a PhD Graduate from the University of Edinburgh. Her research focuses on the content visualized and experienced through visual mental imagery.

Hugo Senra, PhD is a researcher at the Institute of Electronics and Informatics Engineering of Aveiro (IEETA), University of Aveiro (Portugal). His research relates to biostatistics, health related research, clinical trials, and adult mental health.

Karri Gillespie-Smith is a senior lecturer in Applied Psychology. Her research interests are linking neurocognitive mechanisms and social/cognitive processes to mental health outcomes in neurodivergent groups and groups with Intellectual Disabilities.

Matthias Schwannauer is a professor in Clinical Psychology. His current research interests include the application of attachment theory, reflective function and psychological processes of affect regulation to further our understanding of the development, adaptation to and recovery from major mental health problems in adolescence.

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