A new UK-led systematic review in the Journal of Anxiety Disorders by Zenoni, Badaoui, Brewin, Milton, Archer, Bloomfield, and Bisby examined mental imagery in the presentation and treatment of OCD. The authors noted that clinical descriptions and assessments frequently emphasize verbal thoughts, even though obsessions can also be experienced as vivid images, scenes, flashes, bodily sensations, or combinations of these experiences.
Across the included literature, intrusive images were commonly vivid, distressing, predominantly visual, and sometimes accompanied by strong bodily sensations. They were also associated with meanings involving a feared “dangerous self”—for example, an image being interpreted as evidence that the person is violent, immoral, contaminated, sexually deviant, or capable of harming someone. In some of the included samples, as many as 89% of people with OCD reported intrusive imagery; among those reporting images, 70%–79% described some connection with adverse or traumatic experiences. These figures come from heterogeneous studies and should not be treated as precise prevalence estimates for all people with OCD.
The authors therefore concluded that imagery-based interventions should currently be considered adjunctive or investigational, rather than established replacements for ERP.
Clinical Takeaway: During assessment, ask about the form of the obsession rather than assuming it occurs only as verbal thought:
“When the obsession appears, is it a sentence, an image, an urge, a bodily feeling, or some combination?”
Explore the image’s sensory qualities, associated bodily responses, personal meaning, possible memory links, and what the patient does to suppress, cancel, check, neutralize, or obtain certainty about it. A vivid image does not by itself indicate psychosis, recovered memory, genuine intent, or PTSD. Its clinical significance often lies in how the image is appraised and how the person responds to it.
Within ERP, the image itself can become part of the exposure target while the patient refrains from mental reviewing, reassurance, thought replacement, self-testing, avoidance, or other neutralization. Imagery rescripting may eventually prove useful when a recurrent image or adverse memory continues to organize shame, guilt, disgust, or feared-self beliefs, but it should presently supplement—not displace—well-delivered OCD-focused CBT and ERP.