Distressing Memories and Flashforwards in Panic Disorder

Distressing Memories and Flashforwards in Panic Disorder | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Distressing Memories and Flashforwards in Panic Disorder Bart Endhoven, Angelos Miltiadis Krypotos, Nancy Keune, Klara De Cort, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8868800/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Mental images of threat are common in panic disorder and may contribute to its onset and maintenance, making them potential relevant targets for treatment. They can be related to distressing memories or catastrophic future simulations (i.e., “ flashforwards ”). This study explored the similarities and differences between these two types of threat representations in terms of the credibility of encapsulated beliefs, emotional intensity, distress, controllability, aversiveness, sensory complexity, and episodic and semantic details. Methods: Forty-six patients diagnosed with panic disorder were asked about distressing memories and flashforwards related to their disorder using structured audio-recorded interviews and questionnaires before the treatment. The narratives were coded for episodic and semantic details. Results Results showed that both distressing memories and flashforwards were common and highly similar in image characteristics, but overall memories were self-rated as being more sensory-complex. Flashforwards were rated as more aversive, but threat representations did not differ in terms of credibility of encapsulated beliefs, emotional intensity, distress, and controllability. Compared to flashforwards, memories contained more episodic details, but threat representations did not differ in the number of semantic details or in relative scores. Conclusions Distressing memories and flashforwards in panic disorder are highly similar but differ in complexity and perceived aversiveness. The theoretical and clinical implications of distinguishing between these two types of threat representation are discussed. panic disorder episodic memory episodic future thinking mental imagery autobiographical memory flashforwards Figures Figure 1 Figure 2 Figure 3 Introduction Panic disorder is a prevalent and disabling psychiatric condition characterized by persistent fear of panic attacks or their perceived catastrophic consequences (American Psychiatric Association, 2013 ). According to cognitive models, panic attacks result from catastrophic misinterpretations of benign bodily sensations (e.g., heart palpitations, dizziness) as signs of imminent disaster (e.g., heart attack, going crazy; Clark, 1988 ; Barlow, 1988 ; Beck, 1988 ; Aslam et al., 2024 ). Panic attacks can be triggered by external contexts (e.g., locations of prior attacks) or internal cues, such as bodily sensations, distressing thoughts (“ I’m going to have a panic attack ”), or spontaneously occurring mental images (Day et al., 2004 ; Raffa et al., 2004 ; Hewitt et al., 2021 ). Vivid, spontaneously occurring panic-related mental imagery is common in panic disorder and often centers on scenes of perceived threat (Day et al., 2004 ; Ottaviani & Beck, 1987 ). For instance, one individual described such an image as follows: “On a tube train and it stops…Trying not to show fear…Train stopping. Carriages closing in…” (Day et al., 2004 , p. 423). Such aversive mental images can trigger and intensify panic attacks (Clark, 1988 ; Hewitt et al., 2021 ). Experimental research indicates that mental images of threat can elicit avoidance behavior (Krypotos et al., 2020 ), reinforce threat beliefs (van Dis et al., 2024 ), and hinder extinction learning (Mertens et al., 2020 ). Therefore, it has been hypothesized that targeting threat-related mental imagery may enhance treatment outcomes (e.g., Engelhard et al., 2010 ; Brewin et al., 2010 ); however, little is known about the types of mental images patients report. Spontaneously occurring threat imagery in panic disorder is often linked to memories of aversive events in the past (Day et al., 2004 ; Ottaviani & Beck, 1987 ; Wenzel & Cochran, 2006 ). This may include recollections of an initial panic attack, which is frequently perceived as being traumatic (Hewitt et al., 2021 ). Although revisiting such memories can facilitate learning and reflection (Bulley et al., 2017 ; Rasmussen & Berntsen, 2013 ), revisiting distressing memories is no longer adaptive in the context of psychopathology (Brewin et al., 2010 ; Holmes & Mathews, 2010 ). Such memories may be deeply integrated into one’s identity (O'Toole et al., 2016; Conway & Pleydell-Pearce, 2000 ) and contribute to negative schemas about the self, others, and the world (e.g., I am vulnerable; others will not help me; the world is dangerous). In turn, these negative schemas influence how individuals interpret and organize their past, present, and future experiences. Modifying the aversive memories underlying these negative schemas may therefore be a promising approach to directly change threat representations (Moscovitch et al., 2023 ), and clinical studies testing this approach are beginning to emerge (Shibuya et al., 2018 ; Horst et al., 2017 ). Interestingly, mental threat imagery can reflect aversive experiences closely tied to autobiographical memories (Conway & Pleydell-Pearce, 2000 ; Moscovitch et al., 2023 ) but can also arise from other sources, such as elaboration, fantasy, or verbal information (Mertens et al., 2018 , 2020 ; Çili & Stopa, 2022 ). An example of such an elaboration of a distressing event in the past is a patient reporting an image of witnessing his brother’s heart attack despite not having actually witnessed it. Furthermore, it can represent simulations of future threat (e.g., Engelhard et al., 2010 ). For example, one patient reported a future simulation in which he visualized himself having a heart attack during an upcoming restaurant visit (Ottaviani & Beck, 1987 ). Future simulations may have evolved as a preparatory mechanism for managing anticipated threats (Bulley et al., 2017 ; Ji et al., 2016 ; Pearson et al., 2015 ); however, they can also prevent the revision of maladaptive schemas (Moscovitch et al., 2023 ). Memories and future simulations are often schematically linked and rely on overlapping neural mechanisms (Moscovitch et al., 2023 ; Addis et al., 2007, 2008 ). Therefore, the schematic meaning of anxiety-related memories and future simulations may be highly similar (Gehrt et al., 2020 ; Moscovitch et al., 2023 ). Accordingly, interventions aimed at modifying future simulations might also directly change threat representations (Endhoven et al., 2023 ). Although anticipatory catastrophic misinterpretations are central to cognitive models of panic, few phenomenological studies have examined threat imagery in panic disorder (Day et al., 2004 ; Ottaviani & Beck, 1987 ). Future simulations can involve flashforwards, catastrophic future projections of worst fears fueled by anxiety and fantasy (Engelhard et al., 2010 ; Berntsen, 2019 ; Çili & Stopa, 2022 ). Because panic-related memories and flashforwards are potentially schematically linked, the credibility of encapsulated beliefs may not differ substantially. However, memories and flashforwards may differ in several other aspects that may be clinically relevant. For example, stronger emotional activation may facilitate emotional processing (Foa & Kozak, 1986 ). Flashforwards may therefore be experienced as more aversive and may evoke stronger emotions than memories (Schubert et al., 2020 ). However, because memories are typically grounded in past experiences, these mental representations may contain richer sensory and episodic details than flashforwards (Morton & MacLeod, 2023 ). This might also be clinically relevant, as earlier research has shown that individuals with social anxiety report more episodically detailed social anxiety-related memories than non-clinical controls, possibly making these representations more salient and accessible (Moscovitch et al., 2018 ). However, the extent to which anxiety-related memories and flashforwards differ in episodic content has rarely been investigated (Hallford et al., 2018 ; Du et al., 2022 ). To our knowledge, no published research has directly compared the characteristics of distressing memories and flashforwards in panic disorder despite the central role of mental threat representations in the disorder. This study aims to explore both these similarities and differences. We hypothesized that: (1) the credibility of the encapsulated beliefs associated with memories and flashforwards would not differ; (2) flashforwards would elicit greater emotional intensity and would be experienced as more distressing, uncontrollable, and aversive; (3) memories would be self-rated as more sensory-complex representations; and (4) memories would contain more episodic details, both in absolute terms and proportionally, as assessed by the Autobiographical Interview (Levine et al., 2002 , 2009 ). Methods Participants This study was part of a randomized controlled trial investigating the efficacy of Eye Movement and Desensitization and Reprocessing (EMDR) therapy compared to supportive counseling before exposure in vivo for panic disorder. Recruitment, eligibility and the study design are described in Endhoven et al. ( 2023 ). Panic disorder diagnosis was assessed by a clinician or researcher with the Mini-International Neuropsychiatric Interview (M.I.N.I; Overbeek et al., 2019 ; Sheehan et al., 1998 ). Data and materials are available on Open Science Framework ( https://osf.io/czydh/?view_only=a2b6937da40d46e4a0cc600041f6d118 ). The randomized controlled trial was pre-registered (ISRCTN29668369), and the study protocol was approved by the Ethics Review Board of University Medical Center Utrecht (NL73918.041). All participants provided written informed consent. Data from the first 46 participants who completed the mental imagery interview during the case conceptualization session were included in the current study. Our post hoc power calculation in G-power 3.1.9.7, indicated a power of 0.84 for this sample, with f = 0.2, α = 0.05, in a 2 x 3 mixed ANOVA with a 0.5 correction among repeated measures and non-sphericity correction of 1. If data were missing (e.g., no recording) or not usable (e.g., due to a technical error), participants were replaced with the next participant. The sample included 28 females and 18 males, with a mean age of 35.22 years ( SD = 11.93) and a mean score of 24.39 ( SD = 9.09) on the Panic and Agoraphobia Scale (potential range: 0–52; Bandelow, 1995 ). Case conceptualization Distressing memories and flashforwards were assessed before treatment during the case conceptualization session. In this session, the clinician explained the cognitive model of panic disorder (Clark, 1988 ) and asked participants to report all crucial memories they thought contributed to the onset, worsening, or maintenance of their symptoms. The clinician explained that many people also develop future simulations about catastrophes, such as going crazy or getting a heart-attack, which are activated during or in anticipation of anxiety-provoking situations (e.g., heart palpitations in the supermarket), and that these can also maintain the disorder. Next, they were asked to describe their flashforward depicting their worst panic-related fear (i.e., the most terrible outcome of a panic attack). In case they did not report experiencing such imagery, they were helped to create a flashforward by asking them how the most terrible outcome of a panic attack might look like. Eight participants (17%) did not spontaneously report flashforwards, but they were all able to imagine their worst fear. Next, the participants were asked to indicate which image they found most aversive. This was noted by the clinician (see Aversiveness measure below). Finally, the clinician hierarchically ordered images based on the central question: “What memories and flashforwards drive the patient’s panic disorder?”. The memory and flashforward, which were on top of the imagery hierarchy, were selected for the imagery interview. Imagery interview The imagery interview combined sections of the Autobiographical Interview (Levine, 2002) and the interview by Boterhoven de Haan et al. (2017) and was audio-recorded. Participants were informed that the purpose of the imagery interview was to examine how individuals describe and experience mental images and identify potential interindividual differences. When the assessment took place on an even day of the month, the flashforward was assessed first, and the memory afterward, and vice versa on uneven days. During the first phase (“free recall”), participants were asked to close their eyes, describe the image in as much detail as possible, and report everything that came to mind while recalling the image. Afterwards, they were given a general probe, “ keep in mind that we are looking for as many details as possible that you can imagine with this image, including all details you see in the scene, for example, yourself, other people, the background, and details about how you feel when you see this image. Is this everything that you can recall of this image or does anything else come to mind? ”. Next, the participants were asked to score the characteristics of each image, including sensory complexity, emotional intensity, distress, and controllability (see below). Finally, the clinician helped participants to formulate a negative encapsulated belief about self, others, or the world related to this mental image and asked them to rate its credibility. Data processing Audio recordings were transcribed by a research assistant who was blinded to the study hypotheses. The transcripts were then translated into English using ChatGPT (OpenAI, 2024 ) and checked by a research assistant proficient in Dutch and English. Next, prompts by the clinician and uninformative texts (e.g., “I don’t know”) were removed, and the missing punctuation was added. Finally, the transcripts were automatically scored for internal and external elements using a natural language processing model that was trained with datasets of transcripts scored according to the autobiographical interview (see: Levine et al., 2002 ; van Genugten & Schacter, 2024 ). The results of an evaluation study showed that the model performed well across datasets with pre-processed data, including autobiographical memories and future simulations, with high correlations between automated and manual scoring and low misclassification of internal and external elements (Genugten & Schacter, 2024 ). Self-report measures The credibility of the encapsulated belief was assessed with the following question: ‘ How credible do you find this belief? ’ rated on a 0-100 rating scale (0 = Not at all , 100 = Extremely ; Reimer et al., 2015; Boterhoven de Haan et al., 2017). Intensity of negative emotions elicited by the image: anxiety, anger, sadness, guilt, shame, helplessness, numbness, and feeling that something bad is about to happen, were rated on a 5-point scale (1 = Very slightly or not at all , 5 = Extremely ). The scores were summed (Romano et al., 2020 ). Distress evoked by the image was assessed using the following question: “ How distressing is this image to you?” , rated on a 0-100 rating scale (0 = Not at all , 100 = Extremely ; Boterhoven de Haan et al., 2017). Image controllability was assessed with one question: “ To what extent do you feel in control over the content of the image? ” rated on a 0-100 rating scale (0 = Not at all , 100 = Extremely ; Boterhoven de Haan et al., 2017). Image aversiveness was assessed using a forced-choice question: “ Which images are currently bothering you the most? Images of the specter of a future disaster scenario (e.g., that you will have a panic attack in the near future), or images of previous events such as a past panic attack that you often think about?” , responses were coded (1 = Flashforward , 2 = Memory ). Sensory complexity was assessed with the Memory Characteristics Questionnaire (MCQ; Johnson et al., 1988 ), which assesses a wide range of image characteristics (e.g., sensory details, complexity, orientation in time and place), rated on a 7-point scale (e.g., my memory involved visual details: 1 = Little or none , 7 = A lot ). The following 18-items were administered: visual, sound, smell, touch, taste, vividness, storyline complexity, storyline realism), location, setting, spatial orientation (objects and people), time, year, season, day, hour, and overall mood. Scores were summed. Episodic and semantic details Internal and external details of images were based on transcripts that were automatically scored using a natural language processing model trained with datasets of transcripts scored according to the autobiographical interview (see Levine et al., 2002 ; van Genugten & Schacter, 2024 ). Episodic details, such as time, place, and actions, were scored as “ internal ” elements, whereas semantic details, such as facts, common knowledge, etc. were scored as “ external ” elements (Levine et al., 2002 ). First, the number of internal and external details was counted for each image separately. Next, the number of internal details relative to the total number of details (internal + external) was calculated for each image separately. Statistical analyses Because of the established link between memories and future simulations, it is likely that null hypothesis significance testing results in non-significant results. Therefore, we first tested our hypotheses using frequentist analyses, and repeated the analyses with Bayesian alternatives to evaluate the relative likelihood of the data under the alternative hypothesis relative to the null hypothesis, denoted as BF 10 when the frequentist test result was significant, and as BF 01 when it was not (see: Krypotos et al., 2017 for introduction on Bayesian statistics). Data were analyzed using JASP (JASP Team, 2023 ), and nonparametric alternatives were reported when statistical assumptions were violated. If the sphericity assumption was violated, a Greenhouse-Geisser correction was used, and a Bonferroni correction was used in the case of multiple testing. First, to examine whether the credibility of encapsulated beliefs did not differ between memories and flashforwards, a Bayesian alternative for a paired-samples t -test was conducted to evaluate whether the data was more likely under the null hypothesis than the alternative hypothesis (e.g., Krypotos et al., 2017 ). A Bayes factor of BF 01 3 ≥ was considered as support for the data coming from the null hypothesis compared to the alternative one. Second, to test whether flashforwards would elicit greater emotional intensity, distress, uncontrollability, and aversiveness, paired t -tests and chi-square tests were conducted. Third, to evaluate whether memories relative to flashforwards would be self-rated as more sensory-complex, means of image characteristics were displayed in a radar plot, and a paired-samples t -test was conducted on the image composite score. To explore whether memories relative to flashforwards contained more internal details relative to the total number of details, a relative score (internal / [internal +external]) was calculated for each image (Levine et al., 2009 ). A 2 × 3 repeated measures ANOVA was used with time (memory, flashforward) and number of details (internal, external, relative scores) as within-subject variables. Finally, correlations were calculated between the Panic and Agoraphobia Scale and encapsulated beliefs, emotional intensity, distress, controllability, sensory complexity, and internal, external, and relative scores. Results Self-report measures Encapsulated beliefs were mostly related to the self (e.g., I am weak/helpless/a failure; memory 42/43, flashforward 43/45), or others (e.g., Others are insensitive/unwilling to help), but not to the world. It is likely that the credibility of the encapsulated belief does not differ between the two images (BF 01 = 3.77). To test whether flashforwards compared to memories evoke greater emotional intensity, distress, uncontrollability, respectively (non-parametric) paired sample t -tests were conducted, and the results were not significant, respectively t (45) = 0.58, p = 0.567, BF 01 = 5.35, W = 326.00, z = 0.49, p = 0.629, BF 01 = 5.12, W = 263.00, z = -0.31, p = 0.759, BF 01 = 5.09 (see Figs. 1 and 2 ). Descriptive statistics are presented in Table 1 . Taken together, we found evidence that memories and flashforwards do not differ in emotional intensity, distress, and controllability. In total, 38 of the 46 participants spontaneously reported both memories and flashforwards. The remaining eight participants reported memories and were all able to construct a flashforward, and surprisingly, five of them indicated that their constructed flashforward was the most aversive to them. In total, 33 participants (72%) found their flashforward the most aversive, whereas eight participants (17%) found their memory the most aversive, p s < 0.001, BF 10 = 208.49. Two participants could not select an answer because they found both types equally aversive. The image characteristics are shown in Fig. 3 . To test whether memories are more sensory complex than flashforwards, a paired-samples t -test on sensory complexity scores was conducted, and the results were statistically significant ( t (45) = 2.24, p = 0.030, d = 0.33, BF 10 = 1.53). Taken together, memories were rated as more complex than flashforwards. Table 1 Descriptive statistics and correlations with panic and agoraphobia scale Memory Flashforward M (SD) r M (SD) r Encapsulated beliefs 78.44 (18.82) 0.12 81.11 (16.41) 0.22 Emotional intensity 23.72 (6.97) 0.34* 24.28 (6.28) 0.23 Distress 67.61 (25.58) 0.29 70.87 (27.63) 0.19 Controllability 46.30 (30.50) -0.17 45.43 (31.18) -0.03 Sensory complexity 73.48 (19.51) 0.08 66.04 (19.72) 0.05 Internal 181.30 (131.7) 0.04 132.6 (129.50) 0.23 External 27.26 (30.42) 0.17 30.18 (35.26) 0.19 Relative 0.84 (0.18) -0.08 0.83 (0.14) -0.09 *p < .05 Episodic and semantic details To test whether memories relative to flashforwards contain more internal details in absolute and relative terms, a 2 x 3 repeated-measures ANOVA was conducted. The main effect of number of details was statistically significant, F (1.06, 47.74) = 90.79, p < .001, η 2 = 0.52, BF 10 = 0.75. To test whether memories and flashforwards consisted mostly of internal relative to external details, post-hoc analyses were conducted and showed significant main effects between internal and external ( M dif = 128.24, p < 0.001) and between internal and relative ( M dif = 156.12, p < 0.001). The time orientation × number of details interaction was significant F (1.09, 48.92) = 6.09, p = .015, η 2 = 0.02, BF 10 = 1.00. Post-hoc analyses indicated that memories compared to flashforwards contain more internal details in absolute terms ( M dif = 48.75, p = 0.002), but threat representations do not differ on external ( M dif = -2.92, p = 1.000) or on relative scores ( M dif = 0.01, p = 1.000). Taken together, both memories and flashforwards predominantly consist of internal rather than external elements, and they do not differ in terms of external elements. However, memories contain more internal elements in absolute terms but not in relative terms. Discussion This study examined the occurrence, similarities, and differences between distressing memories and flashforwards in patients with panic disorder before treatment. All participants reported panic-related memories, but eight did not spontaneously report flashforwards. Given the central role of anticipated catastrophes in cognitive models of panic disorder, this finding is surprising. Nevertheless, all participants were able to generate a flashforward when prompted, and flashforwards were rated as the most aversive by most participants. These findings align with previous research indicating that vivid mental imagery is common and distressing in individuals with panic disorder, and is often linked to distressing memories (Day et al., 2004 ). Furthermore, memories and flashforwards were generally similar in their characteristics and predominantly consisted of episodic details. However, memories relative to flashforwards were self-rated as sensory more complex representations, and contained more internal details in absolute but not in relative terms. However, both types of imagery were highly similar in emotional intensity, distress, controllability, and credibility of encapsulated beliefs, supporting schema-based models of psychopathology (Moscovitch et al., 2023 ). One explanation for the disparity in spontaneous reporting may be differential accessibility. The constructive episodic simulation hypothesis suggests that future simulations are generated by recombining elements from autobiographical memory and typically contain fewer sensory or contextual details (Schacter et al., 2008 ; Addis et al., 2007; Szpunar, 2010 ). In line with this, participants rated memories as more sensory complex, and these representations contained more internal details. These results mirror the findings in non-clinical samples, where imagined future simulations are often less detailed and complex than memories (Berntsen & Bohn, 2010 ; Morton & MacLeod, 2023 ; De Brigard & Giovanello, 2012 ). Moscovitch et al. ( 2018 ) posited that threat imagery rich in episodic details may be more accessible. To test this assumption, future research could use control groups and/or positive, neutral, or spontaneously occurring imagery to assess differences in accessibility and intrusiveness. This knowledge can inform clinical decision-making and refine cognitive models of panic disorder. Another possibility is that participants avoided generating flashforwards because these future simulations are typically more fantasy-based and less contextually grounded (i.e., they have less sensory complexity and episodic details). Although avoidance was not directly assessed, most participants indicated flashforwards as the most aversive, including five out of eight participants who did not initially report such imagery but constructed it during the interview. These differences cannot be explained by differences in emotionality, distress, or controllability ratings. This null finding contrasts with the findings of a meta-analysis suggesting that future simulations evoke stronger emotions than memories, although most of the included studies involved healthy participants (Schubert et al., 2020 ). In non-clinical samples, future simulations tend to be more positively valanced (Morton & MacLeod, 2023 ), whereas in clinical samples, both memories and future simulations may activate similar negative schemas, producing comparable emotional responses (Moscovitch et al., 2023 ). Future research could use psychophysiological measures to assess differences in psychophysiological responses during memory recall or future simulations (e.g., Kearns & Engelhard, 2015 ). Targeted prompts may also help reduce avoidance and allow for deeper exploration of catastrophic imagery content (Gehrt et al., 2020 ). Using a forced-choice question, most participants indicated that they perceived their flashforward as being the most aversive. More sensitive measurement forms, such as Likert scales, could be used in future research to assess whether memories and future simulations differ in aversiveness. However, one possible explanation for this finding is that future simulations may reflect this perceived immediacy. Prior research suggests that future simulated threats may feel temporally closer than anxiety-related memories, evoking a sense of “here-and-now” (Gehrt et al., 2020 ). Alternatively, future simulations may be interpreted as indicative of actual impending danger, akin to magical thinking or thought-action fusion (Berle & Starcevic, 2005 ). Future simulations might also feel more personally significant or central to identity than memories of past events (Berntsen & Bohn, 2010 ; Rasmussen & Berntsen, 2013 ; D’Argembeau & Garcia Jimenez, 2024 ), as future simulations enhance present-future self-continuity more than memories (D’Argembeau & Garcia Jimenez, 2024 ; Mahr & Schacter, 2024 ). Future research could also investigate the roles of event centrality, self-continuity, and temporal proximity (Berntsen & Rubin, 2007 ; Gehrt et al., 2018 ). Despite their potential clinical relevance, interventions specifically targeting mental threat imagery are rarely applied in panic disorder. Established treatments for other disorders, such as EMDR, prolonged exposure, and imagery rescripting targeting aversive memories, have been shown to reduce anxiety symptomatology (Shapiro, 2018 ; Lewis et al., 2020 ; Lloyd & Marczak, 2022 ; Kip et al., 2023 ). Emerging evidence suggests that these interventions may also reduce the impact of flashforwards (Engelhard et al., 2010 , 2011, 2012; Landkroon et al., 2022 ; Endhoven et al., 2023 ; Thunnissen et al., 2024 ). These approaches may serve both therapeutic and experimental purposes in the future. For example, it allows us to directly test whether targeting flashforwards results in fewer panic symptoms (Aslam et al., 2024 ). However, few clinical studies have examined whether these interventions modify imagery characteristics, alter encapsulated beliefs, or promote approach behavior (but see, e.g., Sheldon et al., 2024 ; van Bentum et al., 2024 ). This study had several limitations. First, this study was not pre-registered, and the sample size was not determined a priori. However, post-hoc power analyses indicated sufficient statistical power, and Bayesian analyses allowed us to provide relative evidence for the null and the alternative hypotheses (see e.g., Krypotos et al., 2017 ). Second, the scoring of autobiographical interview narratives via natural language processing was not independently validated for this dataset, although preprocessing steps were used to optimize model performance (van Genugten & Schacter, 2024 ). Third, the study lacked a control group and neutral or positive imagery conditions, limiting the ability to assess deviations from normative imagery processing. Fourth, we did not assess the differences between probed and spontaneously reported flashforwards. Lastly, we did not measure the frequency or intrusiveness of threat imagery in daily life, which may be of clinical relevance. Ecological momentary assessment designs can address this limitation and minimize recall bias (Cloos et al., 2020 ). This study is the first to compare distressing memories and flashforwards in panic disorder. Strikingly, most participants found flashforwards to be the most aversive, even though some participants did not report these images spontaneously. There was no evidence of differences in emotional intensity, distress, controllability, or credibility of encapsulated beliefs. Threat representations mainly consisted of internal details, whereas memories flashforwards were rated as less complex and contained fewer internal details. These findings provide a foundation for future research and therapeutic interventions targeting imagery processes. Declarations Competing Interests Declarations of interest: Ad de Jongh, Suzy Matthijssen and Agnes van Minnen receive fees from teaching and/or supervising psychologists in EMDR-therapy and/or exposure therapy by means of seminars, workshops, conferences and/or book royalties. All the other authors declare no competing interests. Funding This study was financed with a … grant (…) by the … awarded to …. Author Contribution BE: conceptualization, data curation, formal analysis, methodology, project administration, writing – original draft; AMK: formal analysis, supervision, writing – review and editing, NK: data curation, writing – review and editing; KDC: resources, writing – review and editing, EAMvD: conceptualization, methodology, writing – review and editing; PD: writing – review and editing; AvM: writing – review and editing; ADJ: writing – review and editing; SJMAM: resources, supervision, writing – review and editing; KRJS: resources, writing – review and editing; and IME: conceptualization, methodology, funding acquisition, supervision, writing – review and editing. All authors have approved the final version of the manuscript. Acknowledgement We thank Anastasia Giachanou and Mahdi Kamalabad for their advice regarding text-mining procedures, and Sanne Beishuizen and Amber Morley for their help in pre-processing the data. 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Declarations of interest: Ad de Jongh, Suzy Matthijssen and Agnes van Minnen receive fees from teaching and/or supervising psychologists in EMDR-therapy and/or exposure therapy by means of seminars, workshops, conferences and/or book royalties. All the other authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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12:47:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21263,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRadar plot of the means of the credibility of encapsulated belief, distress, and controllability for memories and flashforwards.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8868800/v1/39966b4b300bc85b18971a17.png"},{"id":103167433,"identity":"9ac0fad1-6a62-485c-a3cd-d610da842964","added_by":"auto","created_at":"2026-02-22 12:47:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32111,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRadar plot of the means of various emotions for memories and flashforwards.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8868800/v1/47fb5de8a19971ed18382b7c.png"},{"id":103167432,"identity":"8d2254db-9f5e-4675-b4b6-678653f557aa","added_by":"auto","created_at":"2026-02-22 12:47:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34270,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRadar plot of the means of various image memory characteristics for memories and flashforwards.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e. SL: story line, SA: spatial arrangement\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8868800/v1/63109c11bbb4ddb6a70e5f6c.png"},{"id":107442907,"identity":"31cbd3bd-f912-48d5-87b8-aa0d318f8584","added_by":"auto","created_at":"2026-04-21 14:12:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":517117,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8868800/v1/a2e07415-5af4-4fbb-a495-222862084ec5.pdf"}],"financialInterests":"Competing interest reported. Declarations of interest: Ad de Jongh, Suzy Matthijssen and Agnes van Minnen receive fees from teaching and/or supervising psychologists in EMDR-therapy and/or exposure therapy by means of seminars, workshops, conferences and/or book royalties. All the other authors declare no competing interests.","formattedTitle":"Distressing Memories and Flashforwards in Panic Disorder","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePanic disorder is a prevalent and disabling psychiatric condition characterized by persistent fear of panic attacks or their perceived catastrophic consequences (American Psychiatric Association, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). According to cognitive models, panic attacks result from catastrophic misinterpretations of benign bodily sensations (e.g., heart palpitations, dizziness) as signs of imminent disaster (e.g., heart attack, going crazy; Clark, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e1988\u003c/span\u003e; Barlow, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1988\u003c/span\u003e; Beck, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1988\u003c/span\u003e; Aslam et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Panic attacks can be triggered by external contexts (e.g., locations of prior attacks) or internal cues, such as bodily sensations, distressing thoughts (\u0026ldquo;\u003cem\u003eI\u0026rsquo;m going to have a panic attack\u003c/em\u003e\u0026rdquo;), or spontaneously occurring mental images (Day et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Raffa et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Hewitt et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVivid, spontaneously occurring panic-related mental imagery is common in panic disorder and often centers on scenes of perceived threat (Day et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Ottaviani \u0026amp; Beck, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e1987\u003c/span\u003e). For instance, one individual described such an image as follows: \u003cem\u003e\u0026ldquo;On a tube train and it stops\u0026hellip;Trying not to show fear\u0026hellip;Train stopping. Carriages closing in\u0026hellip;\u0026rdquo;\u003c/em\u003e (Day et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2004\u003c/span\u003e, p. 423). Such aversive mental images can trigger and intensify panic attacks (Clark, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e1988\u003c/span\u003e; Hewitt et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Experimental research indicates that mental images of threat can elicit avoidance behavior (Krypotos et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), reinforce threat beliefs (van Dis et al., \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and hinder extinction learning (Mertens et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Therefore, it has been hypothesized that targeting threat-related mental imagery may enhance treatment outcomes (e.g., Engelhard et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Brewin et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2010\u003c/span\u003e); however, little is known about the types of mental images patients report.\u003c/p\u003e \u003cp\u003eSpontaneously occurring threat imagery in panic disorder is often linked to memories of aversive events in the past (Day et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Ottaviani \u0026amp; Beck, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e1987\u003c/span\u003e; Wenzel \u0026amp; Cochran, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). This may include recollections of an initial panic attack, which is frequently perceived as being traumatic (Hewitt et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although revisiting such memories can facilitate learning and reflection (Bulley et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Rasmussen \u0026amp; Berntsen, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), revisiting distressing memories is no longer adaptive in the context of psychopathology (Brewin et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Holmes \u0026amp; Mathews, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Such memories may be deeply integrated into one\u0026rsquo;s identity (O'Toole et al., 2016; Conway \u0026amp; Pleydell-Pearce, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) and contribute to negative schemas about the self, others, and the world (e.g., I am vulnerable; others will not help me; the world is dangerous). In turn, these negative schemas influence how individuals interpret and organize their past, present, and future experiences. Modifying the aversive memories underlying these negative schemas may therefore be a promising approach to directly change threat representations (Moscovitch et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and clinical studies testing this approach are beginning to emerge (Shibuya et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Horst et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInterestingly, mental threat imagery can reflect aversive experiences closely tied to autobiographical memories (Conway \u0026amp; Pleydell-Pearce, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Moscovitch et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) but can also arise from other sources, such as elaboration, fantasy, or verbal information (Mertens et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; \u0026Ccedil;ili \u0026amp; Stopa, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). An example of such an elaboration of a distressing event in the past is a patient reporting an image of witnessing his brother\u0026rsquo;s heart attack despite not having actually witnessed it. Furthermore, it can represent simulations of future threat (e.g., Engelhard et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). For example, one patient reported a future simulation in which he visualized himself having a heart attack during an upcoming restaurant visit (Ottaviani \u0026amp; Beck, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e1987\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFuture simulations may have evolved as a preparatory mechanism for managing anticipated threats (Bulley et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Ji et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Pearson et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2015\u003c/span\u003e); however, they can also prevent the revision of maladaptive schemas (Moscovitch et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Memories and future simulations are often schematically linked and rely on overlapping neural mechanisms (Moscovitch et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Addis et al., 2007, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Therefore, the schematic meaning of anxiety-related memories and future simulations may be highly similar (Gehrt et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Moscovitch et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Accordingly, interventions aimed at modifying future simulations might also directly change threat representations (Endhoven et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough anticipatory catastrophic misinterpretations are central to cognitive models of panic, few phenomenological studies have examined threat imagery in panic disorder (Day et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Ottaviani \u0026amp; Beck, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e1987\u003c/span\u003e). Future simulations can involve flashforwards, catastrophic future projections of worst fears fueled by anxiety and fantasy (Engelhard et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Berntsen, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; \u0026Ccedil;ili \u0026amp; Stopa, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Because panic-related memories and flashforwards are potentially schematically linked, the credibility of encapsulated beliefs may not differ substantially. However, memories and flashforwards may differ in several other aspects that may be clinically relevant. For example, stronger emotional activation may facilitate emotional processing (Foa \u0026amp; Kozak, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e1986\u003c/span\u003e). Flashforwards may therefore be experienced as more aversive and may evoke stronger emotions than memories (Schubert et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, because memories are typically grounded in past experiences, these mental representations may contain richer sensory and episodic details than flashforwards (Morton \u0026amp; MacLeod, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This might also be clinically relevant, as earlier research has shown that individuals with social anxiety report more episodically detailed social anxiety-related memories than non-clinical controls, possibly making these representations more salient and accessible (Moscovitch et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, the extent to which anxiety-related memories and flashforwards differ in episodic content has rarely been investigated (Hallford et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Du et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo our knowledge, no published research has directly compared the characteristics of distressing memories and flashforwards in panic disorder despite the central role of mental threat representations in the disorder. This study aims to explore both these similarities and differences. We hypothesized that: (1) the credibility of the encapsulated beliefs associated with memories and flashforwards would not differ; (2) flashforwards would elicit greater emotional intensity and would be experienced as more distressing, uncontrollable, and aversive; (3) memories would be self-rated as more sensory-complex representations; and (4) memories would contain more episodic details, both in absolute terms and proportionally, as assessed by the Autobiographical Interview (Levine et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2002\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThis study was part of a randomized controlled trial investigating the efficacy of Eye Movement and Desensitization and Reprocessing (EMDR) therapy compared to supportive counseling before exposure in vivo for panic disorder. Recruitment, eligibility and the study design are described in Endhoven et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Panic disorder diagnosis was assessed by a clinician or researcher with the Mini-International Neuropsychiatric Interview (M.I.N.I; Overbeek et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Sheehan et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). Data and materials are available on Open Science Framework (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/czydh/?view_only=a2b6937da40d46e4a0cc600041f6d118\u003c/span\u003e\u003cspan address=\"https://osf.io/czydh/?view_only=a2b6937da40d46e4a0cc600041f6d118\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e).\u003c/span\u003e The randomized controlled trial was pre-registered (ISRCTN29668369), and the study protocol was approved by the Ethics Review Board of University Medical Center Utrecht (NL73918.041). All participants provided written informed consent.\u003c/p\u003e \u003cp\u003e Data from the first 46 participants who completed the mental imagery interview during the case conceptualization session were included in the current study. Our post hoc power calculation in G-power 3.1.9.7, indicated a power of 0.84 for this sample, with \u003cem\u003ef\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.2, α\u0026thinsp;=\u0026thinsp;0.05, in a 2 x 3 mixed ANOVA with a 0.5 correction among repeated measures and non-sphericity correction of 1. If data were missing (e.g., no recording) or not usable (e.g., due to a technical error), participants were replaced with the next participant. The sample included 28 females and 18 males, with a mean age of 35.22 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11.93) and a mean score of 24.39 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9.09) on the Panic and Agoraphobia Scale (potential range: 0\u0026ndash;52; Bandelow, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1995\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCase conceptualization\u003c/h3\u003e\n\u003cp\u003eDistressing memories and flashforwards were assessed before treatment during the case conceptualization session. In this session, the clinician explained the cognitive model of panic disorder (Clark, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e1988\u003c/span\u003e) and asked participants to report all crucial memories they thought contributed to the onset, worsening, or maintenance of their symptoms. The clinician explained that many people also develop future simulations about catastrophes, such as going crazy or getting a heart-attack, which are activated during or in anticipation of anxiety-provoking situations (e.g., heart palpitations in the supermarket), and that these can also maintain the disorder. Next, they were asked to describe their flashforward depicting their worst panic-related fear (i.e., the most terrible outcome of a panic attack). In case they did not report experiencing such imagery, they were helped to create a flashforward by asking them how the most terrible outcome of a panic attack might look like. Eight participants (17%) did not spontaneously report flashforwards, but they were all able to imagine their worst fear. Next, the participants were asked to indicate which image they found most aversive. This was noted by the clinician (see Aversiveness measure below). Finally, the clinician hierarchically ordered images based on the central question: \u0026ldquo;What memories and flashforwards drive the patient\u0026rsquo;s panic disorder?\u0026rdquo;. The memory and flashforward, which were on top of the imagery hierarchy, were selected for the imagery interview.\u003c/p\u003e\n\u003ch3\u003eImagery interview\u003c/h3\u003e\n\u003cp\u003eThe imagery interview combined sections of the Autobiographical Interview (Levine, 2002) and the interview by Boterhoven de Haan et al. (2017) and was audio-recorded. Participants were informed that the purpose of the imagery interview was to examine how individuals describe and experience mental images and identify potential interindividual differences. When the assessment took place on an even day of the month, the flashforward was assessed first, and the memory afterward, and vice versa on uneven days. During the first phase (\u0026ldquo;free recall\u0026rdquo;), participants were asked to close their eyes, describe the image in as much detail as possible, and report everything that came to mind while recalling the image. Afterwards, they were given a general probe, \u0026ldquo;\u003cem\u003ekeep in mind that we are looking for as many details as possible that you can imagine with this image, including all details you see in the scene, for example, yourself, other people, the background, and details about how you feel when you see this image. Is this everything that you can recall of this image or does anything else come to mind?\u003c/em\u003e\u0026rdquo;. Next, the participants were asked to score the characteristics of each image, including sensory complexity, emotional intensity, distress, and controllability (see below). Finally, the clinician helped participants to formulate a negative encapsulated belief about self, others, or the world related to this mental image and asked them to rate its credibility.\u003c/p\u003e\n\u003ch3\u003eData processing\u003c/h3\u003e\n\u003cp\u003eAudio recordings were transcribed by a research assistant who was blinded to the study hypotheses. The transcripts were then translated into English using ChatGPT (OpenAI, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and checked by a research assistant proficient in Dutch and English. Next, prompts by the clinician and uninformative texts (e.g., \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;) were removed, and the missing punctuation was added. Finally, the transcripts were automatically scored for internal and external elements using a natural language processing model that was trained with datasets of transcripts scored according to the autobiographical interview (see: Levine et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; van Genugten \u0026amp; Schacter, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The results of an evaluation study showed that the model performed well across datasets with pre-processed data, including autobiographical memories and future simulations, with high correlations between automated and manual scoring and low misclassification of internal and external elements (Genugten \u0026amp; Schacter, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSelf-report measures\u003c/h3\u003e\n\u003cp\u003eThe credibility of the encapsulated belief was assessed with the following question: \u0026lsquo;\u003cem\u003eHow credible do you find this belief?\u003c/em\u003e\u0026rsquo; rated on a 0-100 rating scale (0\u0026thinsp;=\u0026thinsp;\u003cem\u003eNot at all\u003c/em\u003e, 100\u0026thinsp;=\u0026thinsp;\u003cem\u003eExtremely\u003c/em\u003e; Reimer et al., 2015; Boterhoven de Haan et al., 2017).\u003c/p\u003e \u003cp\u003eIntensity of negative emotions elicited by the image: anxiety, anger, sadness, guilt, shame, helplessness, numbness, and feeling that something bad is about to happen, were rated on a 5-point scale (1\u0026thinsp;=\u0026thinsp;\u003cem\u003eVery slightly or not at all\u003c/em\u003e, 5\u0026thinsp;=\u0026thinsp;\u003cem\u003eExtremely\u003c/em\u003e). The scores were summed (Romano et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDistress evoked by the image was assessed using the following question: \u0026ldquo;\u003cem\u003eHow distressing is this image to you?\u0026rdquo;\u003c/em\u003e, rated on a 0-100 rating scale (0\u0026thinsp;=\u0026thinsp;\u003cem\u003eNot at all\u003c/em\u003e, 100\u0026thinsp;=\u0026thinsp;\u003cem\u003eExtremely\u003c/em\u003e; Boterhoven de Haan et al., 2017).\u003c/p\u003e \u003cp\u003eImage controllability was assessed with one question: \u0026ldquo;\u003cem\u003eTo what extent do you feel in control over the content of the image?\u003c/em\u003e\u0026rdquo; rated on a 0-100 rating scale (0\u0026thinsp;=\u0026thinsp;\u003cem\u003eNot at all\u003c/em\u003e, 100\u0026thinsp;=\u0026thinsp;\u003cem\u003eExtremely\u003c/em\u003e; Boterhoven de Haan et al., 2017).\u003c/p\u003e \u003cp\u003eImage aversiveness was assessed using a forced-choice question: \u0026ldquo;\u003cem\u003eWhich images are currently bothering you the most? Images of the specter of a future disaster scenario (e.g., that you will have a panic attack in the near future), or images of previous events such as a past panic attack that you often think about?\u0026rdquo;\u003c/em\u003e, responses were coded (1\u0026thinsp;=\u0026thinsp;\u003cem\u003eFlashforward\u003c/em\u003e, 2\u0026thinsp;=\u0026thinsp;\u003cem\u003eMemory\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eSensory complexity was assessed with the Memory Characteristics Questionnaire (MCQ; Johnson et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1988\u003c/span\u003e), which assesses a wide range of image characteristics (e.g., sensory details, complexity, orientation in time and place), rated on a 7-point scale (e.g., my memory involved visual details: 1\u0026thinsp;=\u0026thinsp;\u003cem\u003eLittle or none\u003c/em\u003e, 7\u0026thinsp;=\u0026thinsp;\u003cem\u003eA lot\u003c/em\u003e). The following 18-items were administered: visual, sound, smell, touch, taste, vividness, storyline complexity, storyline realism), location, setting, spatial orientation (objects and people), time, year, season, day, hour, and overall mood. Scores were summed.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEpisodic and semantic details\u003c/h2\u003e \u003cp\u003eInternal and external details of images were based on transcripts that were automatically scored using a natural language processing model trained with datasets of transcripts scored according to the autobiographical interview (see Levine et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; van Genugten \u0026amp; Schacter, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Episodic details, such as time, place, and actions, were scored as \u0026ldquo;\u003cem\u003einternal\u003c/em\u003e\u0026rdquo; elements, whereas semantic details, such as facts, common knowledge, etc. were scored as \u0026ldquo;\u003cem\u003eexternal\u003c/em\u003e\u0026rdquo; elements (Levine et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). First, the number of internal and external details was counted for each image separately. Next, the number of internal details relative to the total number of details (internal\u0026thinsp;+\u0026thinsp;external) was calculated for each image separately.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eBecause of the established link between memories and future simulations, it is likely that null hypothesis significance testing results in non-significant results. Therefore, we first tested our hypotheses using frequentist analyses, and repeated the analyses with Bayesian alternatives to evaluate the relative likelihood of the data under the alternative hypothesis relative to the null hypothesis, denoted as BF\u003csub\u003e10\u003c/sub\u003e when the frequentist test result was significant, and as BF\u003csub\u003e01\u003c/sub\u003e when it was not (see: Krypotos et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2017\u003c/span\u003e for introduction on Bayesian statistics). Data were analyzed using JASP (JASP Team, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and nonparametric alternatives were reported when statistical assumptions were violated. If the sphericity assumption was violated, a Greenhouse-Geisser correction was used, and a Bonferroni correction was used in the case of multiple testing.\u003c/p\u003e \u003cp\u003eFirst, to examine whether the credibility of encapsulated beliefs did not differ between memories and flashforwards, a Bayesian alternative for a paired-samples \u003cem\u003et\u003c/em\u003e-test was conducted to evaluate whether the data was more likely under the null hypothesis than the alternative hypothesis (e.g., Krypotos et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). A Bayes factor of BF\u003csub\u003e01\u003c/sub\u003e 3\u0026thinsp;\u0026ge;\u0026thinsp;was considered as support for the data coming from the null hypothesis compared to the alternative one. Second, to test whether flashforwards would elicit greater emotional intensity, distress, uncontrollability, and aversiveness, paired \u003cem\u003et\u003c/em\u003e-tests and chi-square tests were conducted. Third, to evaluate whether memories relative to flashforwards would be self-rated as more sensory-complex, means of image characteristics were displayed in a radar plot, and a paired-samples \u003cem\u003et\u003c/em\u003e-test was conducted on the image composite score. To explore whether memories relative to flashforwards contained more internal details relative to the total number of details, a relative score (internal / [internal +external]) was calculated for each image (Levine et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). A 2 \u0026times; 3 repeated measures ANOVA was used with time (memory, flashforward) and number of details (internal, external, relative scores) as within-subject variables. Finally, correlations were calculated between the Panic and Agoraphobia Scale and encapsulated beliefs, emotional intensity, distress, controllability, sensory complexity, and internal, external, and relative scores.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSelf-report measures\u003c/h2\u003e \u003cp\u003eEncapsulated beliefs were mostly related to the self (e.g., I am weak/helpless/a failure; memory 42/43, flashforward 43/45), or others (e.g., Others are insensitive/unwilling to help), but not to the world. It is likely that the credibility of the encapsulated belief does not differ between the two images (BF\u003csub\u003e01\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;3.77).\u003c/p\u003e \u003cp\u003eTo test whether flashforwards compared to memories evoke greater emotional intensity, distress, uncontrollability, respectively (non-parametric) paired sample \u003cem\u003et\u003c/em\u003e-tests were conducted, and the results were not significant, respectively \u003cem\u003et\u003c/em\u003e(45)\u0026thinsp;=\u0026thinsp;0.58, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.567, BF\u003csub\u003e01\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;5.35, W\u0026thinsp;=\u0026thinsp;326.00, \u003cem\u003ez\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.49, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.629, BF\u003csub\u003e01\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;5.12, W\u0026thinsp;=\u0026thinsp;263.00, \u003cem\u003ez\u003c/em\u003e = -0.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.759, BF\u003csub\u003e01\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;5.09 (see Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Descriptive statistics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Taken together, we found evidence that memories and flashforwards do not differ in emotional intensity, distress, and controllability. In total, 38 of the 46 participants spontaneously reported both memories and flashforwards. The remaining eight participants reported memories and were all able to construct a flashforward, and surprisingly, five of them indicated that their constructed flashforward was the most aversive to them. In total, 33 participants (72%) found their flashforward the most aversive, whereas eight participants (17%) found their memory the most aversive, \u003cem\u003ep\u003c/em\u003e\u003csub\u003es\u003c/sub\u003e \u0026lt; 0.001, BF\u003csub\u003e10\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;208.49. Two participants could not select an answer because they found both types equally aversive.\u003c/p\u003e \u003cp\u003eThe image characteristics are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. To test whether memories are more sensory complex than flashforwards, a paired-samples \u003cem\u003et\u003c/em\u003e-test on sensory complexity scores was conducted, and the results were statistically significant (\u003cem\u003et\u003c/em\u003e (45)\u0026thinsp;=\u0026thinsp;2.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.030, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.33, BF\u003csub\u003e10\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;1.53). Taken together, memories were rated as more complex than flashforwards.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescriptive statistics and correlations with panic and agoraphobia scale\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMemory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFlashforward\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEncapsulated beliefs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78.44 (18.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81.11 (16.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.72 (6.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.34*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.28 (6.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67.61 (25.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70.87 (27.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControllability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46.30 (30.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.43 (31.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSensory complexity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.48 (19.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.04 (19.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e181.30 (131.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e132.6 (129.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExternal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.26 (30.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.18 (35.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.84 (0.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83 (0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*p \u0026lt; .05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEpisodic and semantic details\u003c/h2\u003e \u003cp\u003eTo test whether memories relative to flashforwards contain more internal details in absolute and relative terms, a 2 x 3 repeated-measures ANOVA was conducted. The main effect of number of details was statistically significant, \u003cem\u003eF\u003c/em\u003e(1.06, 47.74)\u0026thinsp;=\u0026thinsp;90.79, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, η\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.52, BF\u003csub\u003e10\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.75. To test whether memories and flashforwards consisted mostly of internal relative to external details, post-hoc analyses were conducted and showed significant main effects between internal and external (\u003cem\u003eM\u003c/em\u003e\u003csub\u003edif\u003c/sub\u003e = 128.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and between internal and relative (\u003cem\u003eM\u003c/em\u003e\u003csub\u003edif\u003c/sub\u003e = 156.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The time orientation \u0026times; number of details interaction was significant \u003cem\u003eF\u003c/em\u003e(1.09, 48.92)\u0026thinsp;=\u0026thinsp;6.09, \u003cem\u003ep\u003c/em\u003e = .015, η\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.02, BF\u003csub\u003e10\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;1.00. Post-hoc analyses indicated that memories compared to flashforwards contain more internal details in absolute terms (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003edif\u003c/em\u003e\u003c/sub\u003e = 48.75, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), but threat representations do not differ on external (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003edif\u003c/em\u003e\u003c/sub\u003e = -2.92, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000) or on relative scores (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003edif\u003c/em\u003e\u003c/sub\u003e = 0.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). Taken together, both memories and flashforwards predominantly consist of internal rather than external elements, and they do not differ in terms of external elements. However, memories contain more internal elements in absolute terms but not in relative terms.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the occurrence, similarities, and differences between distressing memories and flashforwards in patients with panic disorder before treatment. All participants reported panic-related memories, but eight did not spontaneously report flashforwards. Given the central role of anticipated catastrophes in cognitive models of panic disorder, this finding is surprising. Nevertheless, all participants were able to generate a flashforward when prompted, and flashforwards were rated as the most aversive by most participants. These findings align with previous research indicating that vivid mental imagery is common and distressing in individuals with panic disorder, and is often linked to distressing memories (Day et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Furthermore, memories and flashforwards were generally similar in their characteristics and predominantly consisted of episodic details. However, memories relative to flashforwards were self-rated as sensory more complex representations, and contained more internal details in absolute but not in relative terms. However, both types of imagery were highly similar in emotional intensity, distress, controllability, and credibility of encapsulated beliefs, supporting schema-based models of psychopathology (Moscovitch et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne explanation for the disparity in spontaneous reporting may be differential accessibility. The constructive episodic simulation hypothesis suggests that future simulations are generated by recombining elements from autobiographical memory and typically contain fewer sensory or contextual details (Schacter et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Addis et al., 2007; Szpunar, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). In line with this, participants rated memories as more sensory complex, and these representations contained more internal details. These results mirror the findings in non-clinical samples, where imagined future simulations are often less detailed and complex than memories (Berntsen \u0026amp; Bohn, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Morton \u0026amp; MacLeod, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; De Brigard \u0026amp; Giovanello, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Moscovitch et al. (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) posited that threat imagery rich in episodic details may be more accessible. To test this assumption, future research could use control groups and/or positive, neutral, or spontaneously occurring imagery to assess differences in accessibility and intrusiveness. This knowledge can inform clinical decision-making and refine cognitive models of panic disorder.\u003c/p\u003e \u003cp\u003eAnother possibility is that participants avoided generating flashforwards because these future simulations are typically more fantasy-based and less contextually grounded (i.e., they have less sensory complexity and episodic details). Although avoidance was not directly assessed, most participants indicated flashforwards as the most aversive, including five out of eight participants who did not initially report such imagery but constructed it during the interview. These differences cannot be explained by differences in emotionality, distress, or controllability ratings. This null finding contrasts with the findings of a meta-analysis suggesting that future simulations evoke stronger emotions than memories, although most of the included studies involved healthy participants (Schubert et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In non-clinical samples, future simulations tend to be more positively valanced (Morton \u0026amp; MacLeod, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), whereas in clinical samples, both memories and future simulations may activate similar negative schemas, producing comparable emotional responses (Moscovitch et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Future research could use psychophysiological measures to assess differences in psychophysiological responses during memory recall or future simulations (e.g., Kearns \u0026amp; Engelhard, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Targeted prompts may also help reduce avoidance and allow for deeper exploration of catastrophic imagery content (Gehrt et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUsing a forced-choice question, most participants indicated that they perceived their flashforward as being the most aversive. More sensitive measurement forms, such as Likert scales, could be used in future research to assess whether memories and future simulations differ in aversiveness. However, one possible explanation for this finding is that future simulations may reflect this perceived immediacy. Prior research suggests that future simulated threats may feel temporally closer than anxiety-related memories, evoking a sense of \u0026ldquo;here-and-now\u0026rdquo; (Gehrt et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Alternatively, future simulations may be interpreted as indicative of actual impending danger, akin to magical thinking or thought-action fusion (Berle \u0026amp; Starcevic, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Future simulations might also feel more personally significant or central to identity than memories of past events (Berntsen \u0026amp; Bohn, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Rasmussen \u0026amp; Berntsen, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; D\u0026rsquo;Argembeau \u0026amp; Garcia Jimenez, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), as future simulations enhance present-future self-continuity more than memories (D\u0026rsquo;Argembeau \u0026amp; Garcia Jimenez, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Mahr \u0026amp; Schacter, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Future research could also investigate the roles of event centrality, self-continuity, and temporal proximity (Berntsen \u0026amp; Rubin, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Gehrt et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite their potential clinical relevance, interventions specifically targeting mental threat imagery are rarely applied in panic disorder. Established treatments for other disorders, such as EMDR, prolonged exposure, and imagery rescripting targeting aversive memories, have been shown to reduce anxiety symptomatology (Shapiro, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lewis et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Lloyd \u0026amp; Marczak, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kip et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Emerging evidence suggests that these interventions may also reduce the impact of flashforwards (Engelhard et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2010\u003c/span\u003e, 2011, 2012; Landkroon et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Endhoven et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Thunnissen et al., \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These approaches may serve both therapeutic and experimental purposes in the future. For example, it allows us to directly test whether targeting flashforwards results in fewer panic symptoms (Aslam et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, few clinical studies have examined whether these interventions modify imagery characteristics, alter encapsulated beliefs, or promote approach behavior (but see, e.g., Sheldon et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; van Bentum et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study had several limitations. First, this study was not pre-registered, and the sample size was not determined a priori. However, post-hoc power analyses indicated sufficient statistical power, and Bayesian analyses allowed us to provide relative evidence for the null and the alternative hypotheses (see e.g., Krypotos et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Second, the scoring of autobiographical interview narratives via natural language processing was not independently validated for this dataset, although preprocessing steps were used to optimize model performance (van Genugten \u0026amp; Schacter, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Third, the study lacked a control group and neutral or positive imagery conditions, limiting the ability to assess deviations from normative imagery processing. Fourth, we did not assess the differences between probed and spontaneously reported flashforwards. Lastly, we did not measure the frequency or intrusiveness of threat imagery in daily life, which may be of clinical relevance. Ecological momentary assessment designs can address this limitation and minimize recall bias (Cloos et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study is the first to compare distressing memories and flashforwards in panic disorder. Strikingly, most participants found flashforwards to be the most aversive, even though some participants did not report these images spontaneously. There was no evidence of differences in emotional intensity, distress, controllability, or credibility of encapsulated beliefs. Threat representations mainly consisted of internal details, whereas memories flashforwards were rated as less complex and contained fewer internal details. These findings provide a foundation for future research and therapeutic interventions targeting imagery processes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003eDeclarations of interest: Ad de Jongh, Suzy Matthijssen and Agnes van Minnen receive fees from teaching and/or supervising psychologists in EMDR-therapy and/or exposure therapy by means of seminars, workshops, conferences and/or book royalties. All the other authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was financed with a \u0026hellip; grant (\u0026hellip;) by the \u0026hellip; awarded to \u0026hellip;.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBE: conceptualization, data curation, formal analysis, methodology, project administration, writing \u0026ndash; original draft; AMK: formal analysis, supervision, writing \u0026ndash; review and editing, NK: data curation, writing \u0026ndash; review and editing; KDC: resources, writing \u0026ndash; review and editing, EAMvD: conceptualization, methodology, writing \u0026ndash; review and editing; PD: writing \u0026ndash; review and editing; AvM: writing \u0026ndash; review and editing; ADJ: writing \u0026ndash; review and editing; SJMAM: resources, supervision, writing \u0026ndash; review and editing; KRJS: resources, writing \u0026ndash; review and editing; and IME: conceptualization, methodology, funding acquisition, supervision, writing \u0026ndash; review and editing. All authors have approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank Anastasia Giachanou and Mahdi Kamalabad for their advice regarding text-mining procedures, and Sanne Beishuizen and Amber Morley for their help in pre-processing the data.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData and materials are available on Open Science Framework (https://osf.io/czydh/?view_only=a2b6937da40d46e4a0cc600041f6d118).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAddis, D. R., Wong, A. T., \u0026amp; Schacter, D. L. (2008). 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Autobiographical memories of anxiety-related experiences. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(3), 329\u0026ndash;341. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0005-7967(03)00142-6\u003c/span\u003e\u003cspan address=\"10.1016/S0005-7967(03)00142-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"panic disorder, episodic memory, episodic future thinking, mental imagery, autobiographical memory, flashforwards","lastPublishedDoi":"10.21203/rs.3.rs-8868800/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8868800/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eMental images of threat are common in panic disorder and may contribute to its onset and maintenance, making them potential relevant targets for treatment. They can be related to distressing memories or catastrophic future simulations (i.e., \u0026ldquo;\u003cem\u003eflashforwards\u003c/em\u003e\u0026rdquo;). This study explored the similarities and differences between these two types of threat representations in terms of the credibility of encapsulated beliefs, emotional intensity, distress, controllability, aversiveness, sensory complexity, and episodic and semantic details.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eForty-six patients diagnosed with panic disorder were asked about distressing memories and flashforwards related to their disorder using structured audio-recorded interviews and questionnaires before the treatment. The narratives were coded for episodic and semantic details.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eResults showed that both distressing memories and flashforwards were common and highly similar in image characteristics, but overall memories were self-rated as being more sensory-complex. Flashforwards were rated as more aversive, but threat representations did not differ in terms of credibility of encapsulated beliefs, emotional intensity, distress, and controllability. Compared to flashforwards, memories contained more episodic details, but threat representations did not differ in the number of semantic details or in relative scores.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDistressing memories and flashforwards in panic disorder are highly similar but differ in complexity and perceived aversiveness. The theoretical and clinical implications of distinguishing between these two types of threat representation are discussed.\u003c/p\u003e","manuscriptTitle":"Distressing Memories and Flashforwards in Panic Disorder","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-22 12:47:40","doi":"10.21203/rs.3.rs-8868800/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"94420e07-b2cb-4936-ba50-d041ff814e41","owner":[],"postedDate":"February 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T14:10:43+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-22 12:47:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8868800","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8868800","identity":"rs-8868800","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}