Clinical features of mental imagery in substance use disorders: A mixed-methods analysis

To characterise the frequency, features and content of craving-related mental imagery among people seeking treatment for substance use disorders (SUDs); examine within-session change in self-reported craving following imagery elicitation; and explore perceived links with autobiographical memory, behavioural, cognitive and emotional responses and imagery triggers.

Mixed-methods observational study incorporating a semi-structured interview and repeated within-session measurement of craving, with quantitative analyses and qualitative content analysis.

A single National Health Service adult community drug and alcohol treatment service in South London, United Kingdom.

Fifty-five adults meeting Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for SUD were recruited between June and December 2019; 33 (60.0%) met criteria for more than one SUD.

The interview assessed craving-related imagery frequency, sensory and affective characteristics, content, autobiographical-memory links, perceived responses and triggers. Craving was measured using the Craving Experience Questionnaire ̶ Strength (CEQ-S11) at baseline, immediately after imagery elicitation and at the end of the interview.

Fifty-one participants (92.7%) reported craving-related imagery. The predominant modality was visual in 49/51 (96.1%); among 50 participants with complete imagery data, 42 (84.0%) described recurrent imagery and 26 (52.0%) reported experiencing it daily. Forty-seven (94.0%) perceived their image as representing an actual event or as strongly associated with autobiographical memory, usually an amalgamation of multiple memories. The 51 images were classified into five overlapping themes: stages of substance consumption (80.4%), the substance itself (84.3%), imagery features (94.1%), sensory experiences and activation (84.3%) and contextual or setting features (96.1%). Among 211 reported triggers, places (21.8%), people (19.9%) and internal moods (17.5%) were most frequent. Mean CEQ-S11 scores were 39.50 at baseline, 48.70 immediately after imagery elicitation and 36.70 at interview end, with an overall effect of time, F(2, 100) = 5.03, P-value 0.008. Among participants with recurrent imagery, 31/42 (73.8%) reported often or always wanting to use the substance following the image, and 34/42 (81.0%) reported that the image often or always persisted until distraction or substance use.

In a mixed-methods study of adults attending a community drug and alcohol treatment service, craving-related mental imagery was commonly reported and was predominantly visual, often recurrent, closely linked to autobiographical memory and associated with perceived urges to use substances.