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Background Psychological trauma, such as witnessing an untimely or gruesome death, commonly provokes intrusive memories that might persist for days to years with adverse effects on individual mental and physical health and functioning. Despite the global prevalence of trauma, scalable evidence-based interventions are absent. Reducing the impact of intrusive memories is crucial for people frequently exposed to trauma, such as health-care workers. This study aimed to determine whether a brief digital imagery-competing task intervention (ICTI) reduced intrusive memory frequency after 4 weeks. Harms were also assessed. Methods The GAINS-02 decentralised digital, parallel-group Bayesian adaptive randomised controlled trial tested a brief ICTI against an active control and treatment as usual to determine the effect on reducing intrusive memory frequency. Health-care workers in facilities that admitted patients with COVID-19 during the pandemic, who had experienced one or more traumatic events and reported at least three intrusive memories in the week before screening were randomised 2:2:1 (ICTI to active control to treatment as usual) via block randomisation (web-based). ICTI and active control participants were masked to treatment allocation, and both had one guided session then optional self-use. ICTI involved image-based memory retrieval then Tetris computer gameplay with mental rotation. The active control involved a music-listening task. Study statisticians were masked to ICTI and active control group. The primary outcome was the number of intrusive memories in week 4 (controlling for baseline), which was evaluated on an intention-to-treat basis. Treatment effects for the intervention group versus the comparator groups were assessed using Bayes regression analyses. Harms were assessed through adverse event reporting and interim analyses on primary outcome. People with lived experience were involved from study conception and throughout the research and writing process. The trial was pre-registered at clinicaltrials.gov (NCT05616676) and is completed. Findings Between Dec 8, 2022, and Sept 15, 2023, 176 participants were screened and 99 included (ICTI n=40, active control n=39, treatment as usual n=20) with mean age 41 & centerdot;2 years (SD 10 & centerdot;2; range 21-62). Of these 99 participants, 85 (86%) self-identified as women and 89 (90%) as White. Bayesian analyses gave robust evidence that ICTI reduced intrusive memories at week 4: ICTI participants reported fewer intrusive memories (median 0 & centerdot;5 [IQR 0 & centerdot;0-5 & centerdot;0]) compared with the active control (active control 5 & centerdot;0 [3 & centerdot;0-11 & centerdot;5]; Bayes factor [BF](active control>ICTI vs active control=ICTI) 114 & centerdot;1; beta(active control>ICTI) 1 & centerdot;29 [95% CrI 0 & centerdot;64-2 & centerdot;00]) and treatment as usual (median 5 & centerdot;0 [IQR 2 & centerdot;5-8 & centerdot;0]; BFtreatment as usual>ICTI vs treatment as usual=ICTI=15 & centerdot;8; beta(treatment as usual>ICTI) 1 & centerdot;21 [95% CrI 0 & centerdot;49-1 & centerdot;98]) groups. No harms were detected for ICTI relative to the active control and treatment as usual. The most reported adverse event (n=7) was COVID-19. Two adverse events involved burden of diary recording. Serious adverse events were hospitalisations unrelated to study procedures (n=6). Interpretation This study shows that ICTI reduces intrusive memory frequency and post-traumatic stress disorder symptoms among health-care workers exposed to trauma. As a brief, scalable digital intervention, ICTI shows promise for mitigating consequences of trauma on mental health, an important and unmet need for health-care personnel and systems worldwide.

Psychological treatments for depression are effective but about half of the patients do not improve in treatment suggesting a need for treatment innovation. Evidence-based treatments, such as Behavioral Activation (BA), aim to increase rewarding activities in daily life. Lab-based research has shown that by generating mental imagery of potentially rewarding activities (rather than thinking about them verbally) individuals can alter their appraisals of these activities, increasing anticipated pleasure and motivation. However, BA does not explicitly encourage patients to use mental imagery when scheduling activities. The present randomized controlled parallel two-arm trial tested a novel imagery-enhanced BA intervention (Web-based Imagery Behavioral Activation or WIMBA) delivered online in a sample of N = 168 adults from Germany fulfilling diagnostic criteria for a major depressive episode. Participants were randomized 1:1 to four brief, unguided online WIMBA sessions or to a wait-list control condition (without active treatment components). WIMBA comprised four weekly sessions including psychoeducation, imagery-enhanced activity scheduling, and personalized feedback. Primary outcome measures were the Behavioral Activation for Depression Scale - Short Form and the Beck Depression Inventory-II. Intention-totreat analyses showed significantly higher increases in behavioral activation for WIMBA compared to wait-list from session 3 which sustained through follow-up (baseline to follow-up increase of 9.4, d = 1.0). Depressive symptoms decreased significantly more after WIMBA (baseline to follow-up decrease of 9.3, d = 1.1). Dropout data and participant feedback support good acceptability and feasibility of WIMBA. Unguided web-delivered imagery-enhanced BA offers promise for scalability and further trials, including an active control, are warranted.

Trial preregistration: https://osf.io/97wuf

Experimental psychopathology (EPP) historically relied on extensive experimenter training, but this has dwindled in recent years. Insufficient training may lead to increased 'experimenter noise' and 'protocol drift', potentially hindering the fidelity and replicability of EPP research. This may ultimately impact translation of findings from the laboratory to the clinic, decelerating the development of novel psychological interventions. In an effort to address this, we made a first attempt to develop experimenter training guidance for EPP researchers, using the example of the trauma film paradigm (TFP). In a pragmatic review of articles on methodological guidance for laboratory-based EPP paradigms, we identified only seven articles, just one of which provided an explicit framework for experimenter training. Incorporating insights from the reviewed articles, together with approaches employed in adjacent clinical trials, we suggest a possible framework for experimenter training in EPP. The framework includes overarching principles of experimenter training, steps in a training process, an approach to evaluating training outcomes, and offers examples from the TFP. Further work is needed, and future directions include incentivizing, improving, disseminating and experimentally testing guidance for experimenter training in EPP. Critically, as we have seen in previous decades, this may even ultimately aid the turbulent translational pipeline of new techniques from the laboratory to evidence-based psychological therapies grounded in scientific principles.

Mental imagery is a powerful cognitive process implicated in various psychological disorders, yet its role in chronic pain remains underexplored. This study examined the temporal relationship between mental imagery, pain-related psychological constructs, and pain outcomes in young adults with chronic pain. A sample of 121 university students with chronic pain completed baseline assessments of mental imagery (tendency, ability, intrusive imagery), pain-related psychological constructs (interpretation bias, fear of progression, pain anxiety), and general psychological constructs (depression, anxiety, stress, emotion regulation difficulties, trauma symptoms). Participants then completed an ecological momentary assessment delivered by smartphone app 3 times daily for 1 week, reporting on pain severity, pain interference, pain-related imagery (frequency, valence, vividness), and pain expectancy. Multilevel and cross-lagged models were used to assess within- and between-person predictors of pain outcomes. We found that pain-specific imagery, particularly intrusive imagery at baseline and momentary imagery frequency, was consistently associated with greater pain severity and interference, and predicted subsequent pain severity. General imagery tendency was inversely associated with pain outcomes, suggesting a potential protective effect. Increased pain imagery valence and vividness were differentially associated with increased pain severity and interference, respectively. Pain expectancy, interpretation bias, and fear of progression were also significant predictors of pain interference, while pain expectancy also predicted subsequent pain severity. These findings suggest that pain-specific mental imagery is a temporally relevant and potentially modifiable predictor of pain outcomes in young adults.

Background:There is a need for scalable and simple interventions for trauma-exposed people. In this case series, we built on our previous case study and case series findings and further explored the use and potential effectiveness of a brief novel intervention to reduce the number of past intrusive memories of trauma. The imagery competing task intervention consists of a memory reminder and the visuospatial task Tetris played with mental rotation, targeting 1 intrusive memory at a time. Here, we test remote delivery of the intervention, including guidance from researchers without specialist mental health training, in a sample of women in Iceland with current intrusive memories from trauma.

Objective: In a case series of trauma-exposed women, we aimed to explore whether this brief novel intervention reduces the number of established intrusive memories (primary outcome) and improves general functioning and symptom reduction in posttraumatic stress, depression, and anxiety (secondary outcomes). The acceptability of the intervention along with adaptations, that is, delivery by psychology students without specialist mental health training and digital delivery, was explored.

Methods: Participants (N=8) monitored the number of intrusive memories from an index trauma (occurring 3-16 years previously) in a daily diary at baseline, during the intervention, and postintervention at 1-month and 3-month follow-ups. The intervention was delivered digitally with guidance from clinical psychologists or psychology students. A repeated AB design was used ("A": preintervention baseline, "B": intervention phase). Intrusions were targeted one by one, creating repetitions of an AB design (ie, length of baseline "A" and intervention "B" varied for each memory).

Results: The number of intrusive memories reduced for all participants from the baseline phase compared with the intervention phase, although the reduction was minimal for 2 participants (6.3%-93%). The number of intrusive memories continued to reduce for 6 out of 8 participants (58%-100% reduction at 1-month follow-up; 72%-100% reduction at 3-month follow-up). Symptoms of posttraumatic stress, depression, and anxiety were reduced for most participants postintervention and continued to decrease during the follow-up periods. Functioning was improved for 7 of the 8 participants from baseline to postintervention and continued to improve at the follow-up assessments for 3 participants. The intervention delivered digitally and partly by students was perceived to be an acceptable way to reduce the frequency of intrusive memories by all participants (mean rating 9.5 out of 10).

Conclusions: Data from this case series of traumatized women provide preliminary evidence for the effectiveness of this novel brief intervention in reducing intrusive memories of trauma occurring several years ago and in improving functioning and reducing core symptom burden. This study will inform a randomized controlled trial of this novel intervention, which may have considerable implications for large-scale clinical management of traumatized populations.

Trial Registration: ClinicalTrials.gov NCT04209283; https://clinicaltrials.gov/study/NCT04209283 International Registered Report Identifier (IRRID): RR2-10.2196/29873

Psychological trauma for those utilising and delivering healthcare is common, and in particular the experience of repeated and unwanted intrusive memories (IM) of the trauma can occur. There are several psychological interventions that have been shown to be effective with the full syndrome of Post Traumatic Stress Disorder (PTSD), but researchers have only recently explored targeted interventions for IMs. This review provides a summary of a body of work on a behavioural technique called "Imagery Competing Task Intervention" (ICTI) for intrusive memories after trauma by Holmes and colleagues. The papers presented outline the underlying cognitive science, the historical development of the intervention, and its application to various different populations in healthcare settings including clinical tests of efficacy. Settings and populations include traumatic events experienced by emergency department patients and emergency caesarean section patients, as well as after work-related trauma experienced by intensive care staff and wider healthcare staff. Timing of ICTI intervention delivery has included the same day of trauma, within 72 h and for older memories weeks, months (or years) post-trauma. The intervention has been delivered with a guided session, which in some studies is in person and some remotely via digital health application. There is a brief overview of other related interventions. The ICTI approach shows potential scalability in trauma laden environments such as healthcare, where exposure is unlikely to be limited or managed and symptoms such as subclinical IMs are common. As such the intervention could be used in a preventing-and-treating approach and in subclinical-to-clinical samples who have IMs after exposure to psychological trauma. Future research would be needed to test ICTI as an intervention for the full syndrome of PTSD.

Trauma prevalence is vast globally. Evidence-based digital treatments can help, but most require human guidance. Human guides provide tailored instructions and responsiveness to internal states, but limit scalability. Might generative AI and neurotechnology provide a scalable alternative? Here we provide a first test of ANTIDOTE, combining AI guidance and pupillometry to automatically deliver and monitor the Imagery Competing Task Intervention (ICTI). ICTI is a digital intervention developed by our group to reduce intrusive memories after psychological trauma, previously delivered with human guidance. One hundred healthy volunteers were exposed to videos of traumatic events and randomized to an intervention or active control condition. As predicted, intervention participants reported significantly fewer intrusive memories over the following week. Post hoc assessments confirmed the AI guide delivered the intervention successfully. Pupil size tracked intervention engagement and was associated with symptom reduction, providing a candidate biomarker. These findings suggest a path towards developing AI-guided digital interventions with scalability potential.

Background:

This study examined psychological reactions to perceived threats, viewed within the context of human evolutionary history. We compared the relative weight of perceived threat to life or physical harm versus social threat, i.e., humiliation and/or rejection, in symptoms of posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD).

Methods:

Participants were 50 women with clinically significant posttraumatic stress symptoms (PTSS) and 59 women with little or no PTSS (control group) selected from a large, population-based cohort of women in Iceland, the SAGA Cohort. Participants rated (1) life threat, (2) physical threat, (3) humiliation, and (4) rejection during their worst trauma or stressor.

Results:

Rates of both life and social threats were higher in the PTSS than control group. Among the PTSS participants, 4 % (n = 2) reported primarily life threats (vs. 6.8 %, n = 4 in controls), 36 % (n = 18) reported primarily social threats (vs. 33.9 %, n = 20 in controls), and 60 % (n = 30) reported both types of threats (vs. 15.3 %, n = 9 in controls). Those who reported dual life and social threats exhibited elevated PTSS compared to those who experienced a single type of threat. The highest levels of life or physical threat, along with humiliation, predicted PTSS severity, but rejection did not. Nearly half of the PTSS group (approximately 50 %, n = 25) also met criteria for SAD compared to roughly 14 % (n = 8) in the control group, and humiliation predicted SAD symptom severity. Notably, 18 % of the PTSS group (n = 9) linked the onset of their SAD and PTSS to a singular trauma or stressor involving a social threat.

Conclusions:

The findings underscore the role of social threat in PTSD and SAD, with implications for theoretical models of both disorders.

User engagement remains a challenge in digital mental health. This editorial reconsiders engagement as a process rather than an outcome, introducing a four-step model to define, measure and link engagement to outcomes. The approach promotes standardisation, interpretability and scalability, advancing the science and implementation of digital health interventions.