Mental imagery and its role in the psychopathology and treatment of obsessive-compulsive disorder: A systematic review and narrative synthesis

Whilst intrusive mental images are recognised within diagnostic descriptions of obsessions in OCD, research remains limited, with most work focusing on intrusive thoughts. Moreover, it has been suggested that mental imagery might represent a distinct form of OCD symptomatology and could potentially be harnessed to treat symptoms. We performed a systematic review, adopting a two-phased approach, to examine the role of mental imagery in both the psychopathology and treatment of OCD. First, we explored the characteristics and pathological features of intrusive imagery in OCD. Second, we evaluated literature examining imagery-based interventions, i.e., Imagery Rescripting (ImRs) and Eye Movement Desensitisation and Reprocessing (EMDR), in treating symptoms. Findings from the included studies suggest that distressing mental imagery is a clinically relevant feature of OCD for a substantial proportion of affected individuals. Intrusive imagery in OCD was commonly characterised as vivid, distressing, predominantly visual images often accompanied by bodily sensations. Compared to other anxiety disorders, intrusive imagery in OCD appeared to occur more frequently and was associated with appraisals involving fears of having a "dangerous self" or being a threat to others. Up to 89% of OCD patients reported experiencing intrusive imagery, with 70-79% of these also reporting that the intrusions related to adverse or traumatic events. Image-based treatments such as ImRs and EMDR appear promising, but the evidence base remains heterogeneous and methodologically limited. Accordingly, these approaches should currently be considered adjunctive or investigational pending further adequately powered trials with standardised protocols.