Intrusive images in psychological disorders: characteristics, neural mechanisms, and treatment implications
Open accessAbstract
Involuntary images and visual memories are prominent in many types of psychopathology. Patients with posttraumatic stress disorder, other anxiety disorders, depression, eating disorders, and psychosis frequently report repeated visual intrusions corresponding to a small number of real or imaginary events, usually extremely vivid, detailed, and with highly distressing content. Both memory and imagery appear to rely on common networks involving medial prefrontal regions, posterior regions in the medial and lateral parietal cortices, the lateral temporal cortex, and the medial temporal lobe. Evidence from cognitive psychology and neuroscience implies distinct neural bases to abstract, flexible, contextualized representations (C-reps) and to inflexible, sensory-bound representations (S-reps). We revise our previous dual representation theory of posttraumatic stress disorder to place it within a neural systems model of healthy memory and imagery. The revised model is used to explain how the different types of distressing visual intrusions associated with clinical disorders arise, in terms of the need for correct interaction between the neural systems supporting S-reps and C-reps via visuospatial working memory. Finally, we discuss the treatment implications of the new model and relate it to existing forms of psychological therapy.
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Intrusive memories of unpleasant experiences are common in most psychiatric disorders.
“Whereas it was originally believed that intrusive memories of unpleasant experiences were a unique symptom of PTSD, it is now known that this symptom is common in most psychiatric disorders [7].”
From Memory and Forgetting (2018) · cites this paper as [7]
The Naturalistic Studies summary (page not provided) says intrusive images and memories are common in many disparate psychological conditions and are often linked to adverse events. This supports their occurrence beyond PTSD, but the paper says “many,” not “most,” disorders; it also discusses intrusive images as well as memories of unpleasant experiences. (LLM, conf=0.82)
Experimental — accuracy not yet measuredAll clinical theories of PTSD require the existence of a specialized long-term perceptual memory system that is functionally independent of episodic memory.
“All these theories therefore require the existence of a specialized longterm perceptual memory system that is functionally independent of episodic memory.”
From Episodic memory, perceptual memory, and their interaction: Foundations for a theory of posttraumatic stress disorder. (2014) · cites this paper as Brewin, Gregory, Lipton, & Burgess, 2010
The Abstract (page not available in our copy) says some influential clinical theories propose a second sensory memory system, supporting that part of the claim. It does not say all PTSD theories require one; it also describes a clinical account based on increased stimulus priming and contrasts single-system accounts. (LLM, conf=0.88)
Experimental — accuracy not yet measuredPerceptual memories consist of 'sensation-near' representations ('S-reps') which are the product of processing in the dorsal visual stream, insula, and amygdala, and which are specialized for action on the environment.
“The authors suggest that these perceptual memories consist of 'sensation-near' representations ('S-reps') which are the product of processing in the dorsal visual stream, insula, and amygdala, and which are specialized for action on the environment.”
From Episodic memory, perceptual memory, and their interaction: Foundations for a theory of posttraumatic stress disorder. (2014) · cites this paper as Brewin, et al., 2010
In 'A Neurocognitive Model of Healthy Memory and Imagery' (page unavailable), the paper defines S-reps as low-level, sensation-based representations. The revised theory's Summary (page unavailable) associates them with the dorsal visual stream and its connections to the amygdala and insula. The passages do not say that S-reps are specialized for action on the environment. (LLM, conf=0.82)
Experimental — accuracy not yet measuredVery high levels of stress lead to a corresponding reduction of activity in the ventral visual stream and medial temporal lobe, where elements of objects and scenes are normally bound together and encoded in an abstract form.
“Very high levels of stress also lead to a corresponding reduction of activity in the ventral visual stream and medial temporal lobe, where the elements of objects and scenes are normally bound together and encoded in an abstract form.”
From Memory and Forgetting (2018) · cites this paper as [7]
In “Intrusive Images in Posttraumatic Stress Disorder” (page unavailable), the paper says high stress has deleterious effects on hippocampal functioning and predicts weaker contextual representations. Its Summary (page unavailable) links those representations to the ventral visual stream and medial temporal lobe. It does not establish the claimed corresponding reduction in activity across both regions; that states the proposed mechanism more definitively than the paper does. (LLM, conf=0.84)
Experimental — accuracy not yet measuredAccording to the revised dual representation theory of PTSD, flashbacks depend on a stress-related excess of activity in the dorsal visual stream.
“According to the revised dual representation theory of PTSD [7, 15], flashbacks depend on a stress-related excess of activity in the dorsal visual stream, which is specialized for creating images of the environment from a first-person (egocentric) perspective that can be used to direct immediate motor responses to threat.”
From Memory and Forgetting (2018) · cites this paper as [7]
In “Intrusive Images in Posttraumatic Stress Disorder” (page unavailable), the revised model links flashbacks to enduring representations formed during extreme stress, and the Summary associates those representations with the dorsal visual stream. But the paper specifies a second necessary condition—their lack of integration with contextual representations—and does not state that flashbacks depend on excess dorsal-stream activity alone. (LLM, conf=0.84)
Experimental — accuracy not yet measured
Participants often experienced memory-based intrusive mental imagery during anxiety, rather than the future-based imagery characteristic of neurotypical anxiety.
“Participants often experienced memory-based intrusive MI during anxiety, rather than the future-based imagery characteristic of neurotypical anxiety (Brewin et al., 2010).”
From Understanding Autistic Adults' Psychological Experiences of Anxiety Problems: A Qualitative Interview Study. (2026) · cites this paper as Brewin et al., 2010
The Other Anxiety Disorders section reports that intrusive images in social phobia and agoraphobia were often linked to earlier adverse memories. But the Summary says future-oriented images have usually been studied in anxiety disorders and cautions against a clear separation of memory- and future-based images. It does not establish that future-based imagery is characteristic of neurotypical anxiety in contrast to the citing document’s participants (page numbers unavailable). (LLM, conf=0.86)
Experimental — accuracy not yet measuredA hypothesised shift from contextual towards perceptual-based processing during trauma is a key feature of cognitive models of PTSD.
“a hypothesised shift from contextual towards perceptual-based processing during trauma is a key feature of cognitive models of PTSD (Brewin et al., 2010; Ehlers & Clark, 2000).”
From Intrusive memories of trauma: A target for research bridging cognitive science and its clinical application (2019) · cites this paper as Brewin et al., 2010
Although involuntary memories are an essentially normal phenomenon, what distinguishes those occurring in PTSD is that they typically involve a small number of traumatic scenes that are repeatedly reexperienced.
“Although involuntary memories are an essentially normal phenomenon (Brewin, Christodoulides, & Hutchinson, 1996), what distinguishes those occurring in PTSD is that they typically involve a small number of traumatic scenes that are repeatedly reexperienced (Brewin, et al., 2010).”
From Episodic memory, perceptual memory, and their interaction: Foundations for a theory of posttraumatic stress disorder. (2014) · cites this paper as Brewin, et al., 2010
According to dual representation theory, traumatic memories are characterized by an imbalance between sensory representations and contextual representations, such that sensory components are increased at the expense of the memory's contextualization and narrative.
“According to dual representation theory [65], traumatic memories are characterized by an imbalance between sensory representations and contextual representations, such that sensory components (body sensations, emotions, images, smells) are increased at the expense of the memory’s contextualization and narrative.”
From Childhood trauma and subclinical PTSD symptoms predict adverse effects and worse outcomes across two mindfulness-based programs for active depression (2025) · cites this paper as [65]
C-reps are the product of processing in the ventral visual stream and medial temporal lobe.
“proposing parallel contextualized representations ('C-reps') that are the product of processing in the ventral visual stream and medial temporal lobe”
From Episodic memory, perceptual memory, and their interaction: Foundations for a theory of posttraumatic stress disorder. (2014) · cites this paper as Brewin et al., 2010
For these reasons, exposure therapy is often thought to rely on other processes such as habituation, UCS revaluation, or contextualization.
“For these reasons, exposure therapy is often thought to rely on other processes such as habituation [46], UCS revaluation [56], or contextualization [7].”
From Memory and Forgetting (2018) · cites this paper as [7]
Intrusive memories comprise a core clinical feature of post-traumatic stress disorder (PTSD).
“in PTSD they comprise a core clinical feature”
From Intrusive memories of trauma: A target for research bridging cognitive science and its clinical application (2019) · cites this paper as Brewin, Gregory, Lipton, & Burgess, 2010
Intrusive mental imagery is important in the development and maintenance of anxiety disorders.
“Finally, there is increasing recognition that intrusive MI is important in the development and maintenance of anxiety disorders (Brewin et al., 2010) but has only been explored in autistic individuals across two studies.”
From Understanding Autistic Adults' Psychological Experiences of Anxiety Problems: A Qualitative Interview Study. (2026) · cites this paper as Brewin et al., 2010
Seventy percent of the sample endorsed experiencing intrusive mental imagery during anxiety, a rate comparable to neurotypical populations.
“Seventy percent of our sample endorsed experiencing intrusive MI during anxiety, a rate comparable to neurotypical populations (Brewin et al., 2010).”
From Understanding Autistic Adults' Psychological Experiences of Anxiety Problems: A Qualitative Interview Study. (2026) · cites this paper as Brewin et al., 2010
The citation is attached to the comparison with neurotypical populations; the 70% figure describes the citing authors’ own sample. Brewin et al.’s Naturalistic Studies summary says recurrent intrusions occur in healthy controls but are significantly less common than in clinical groups. The passages found do not give a healthy-population rate for intrusive imagery during anxiety, so they cannot establish whether 70% is comparable. (LLM, conf=0.72)
Experimental — accuracy not yet measuredIntrusive memories have been theorized to play a critical role in the development and maintenance of various psychological disorders, including PTSD, depression, bipolar disorder, social anxiety, agoraphobia, spider phobia, and health anxiety.
“‘Intrusive memories’—typically of emotional events—are a form of involuntary recall and have been theorized to play a critical role in the development and maintenance of various psychological disorders [24–29], such as PTSD, and also including depression [30,31], bipolar disorder [32,33], social anxiety [34], agoraphobia [35], spider phobia [36] and health anxiety [37].”
From Multiple memory systems, multiple time points: How science can inform treatment to control the expression of unwanted emotional memories (2018) · cites this paper as [26]
Trauma memories tend to be encoded in predominantly sensory modalities, with a fragmented and disorganized sequencing, thereby reducing the likelihood that the memory is adequately embedded into one's autobiographical memory base.
“They tend to be encoded in predominantly sensory modalities, with a fragmented and disorganized sequencing, thereby reducing the likelihood that the memory is adequately embedded into one's autobiographical memory base 102 .”
From Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges (2019) · cites this paper as [102]
Cognitive models propose that trauma memories are encoded in a distinctive manner as a result of elevated arousal at the time of trauma.
“Cognitive models propose that trauma memories are encoded in a distinctive manner, as a result of the elevated arousal at the time of trauma.”
From Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges (2019) · cites this paper as [102]
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A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD
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Self-citationPost‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges
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Self-citationImagery rescripting as a clinical intervention for aversive memories: A meta-analysis
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Prospective mental imagery in patients with major depressive disorder or anxiety disorders
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Out-of-body-induced hippocampal amnesia
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A multisite analysis of the fluctuating course of posttraumatic stress disorder
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Sleep promotes lasting changes in selective memory for emotional scenes
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Schema Therapy for Personality Disorders—A Review
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Self-compassion, trauma, and posttraumatic stress disorder: a systematic review
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Cognitions in bipolar affective disorder and unipolar depression: imagining suicide
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Embodying Compassion: A Virtual Reality Paradigm for Overcoming Excessive Self-Criticism
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Kleim, B., Graham, B., Bryant, R. A., & Ehlers, A. (2013) · Journal of Abnormal Psychology · doi:10.1037/a0034957 · Cited by 121 · see citing works
Wade, D. M., Brewin, C. R., Howell, D. C. J., White, E., Mythen, M. G., & Weinman, J. A. (2015) · British Journal of Health Psychology · doi:10.1111/bjhp.12109 · Cited by 119 · see citing works
Self-citationAn fMRI investigation of posttraumatic flashbacks
Whalley, M. G., Kroes, M. C. W., Huntley, Z., Rugg, M. D., Davis, S. W., & Brewin, C. R. (2013) · Brain and Cognition · doi:10.1016/j.bandc.2012.10.002 · Cited by 115 · see citing works
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Visser, R. M., Lau-Zhu, A., Henson, R. N., & Holmes, E. A. (2018) · Philosophical Transactions of the Royal Society B: Biological Sciences · doi:10.1098/rstb.2017.0209 · Cited by 95 · see citing works
Intrusive memories to traumatic footage: the neural basis of their encoding and involuntary recall
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Post-traumatic stress disorder: a right temporal lobe syndrome?
Engdahl, B., Leuthold, A. C., Tan, H.-R. M., Lewis, S. M., Winskowski, A. M., Dikel, T. N., & Georgopoulos, A. P. (2010) · Journal of Neural Engineering · doi:10.1088/1741-2560/7/6/066005 · Cited by 97 · see citing works
Heart rate variability predicts control over memory retrieval.
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Posttraumatic intrusive symptoms across psychiatric disorders
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Vividness of general mental imagery is associated with the occurrence of intrusive memories
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A systematic literature review of the impact of art therapy upon post-traumatic stress disorder
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Brewin, C. R. (2018) · Current Psychiatry Reports · doi:10.1007/s11920-018-0950-7 · Cited by 70 · see citing works
Self-citationA review on mental imagery in fear conditioning research 100 years since the ‘Little Albert’ study
Mertens, G., Krypotos, A.-M., & Engelhard, I. M. (2020) · Behaviour Research and Therapy · doi:10.1016/j.brat.2020.103556 · Cited by 69 · see citing works
Bisby, J. A., King, J. A., Brewin, C. R., Burgess, N., & Curran, H. V. (2010) · Biological Psychiatry · doi:10.1016/j.biopsych.2010.01.010 · Cited by 65 · see citing works
Self-citationDeeprose, C., Zhang, S., DeJong, H., Dalgleish, T., & Holmes, E. A. (2012) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2011.10.008 · Cited by 65 · see citing works
Rosellini, A. J., & Brown, T. A. (2019) · Psychological Assessment · doi:10.1037/pas0000649 · Cited by 64 · see citing works
Incubation of depression: ECM assembly and parvalbumin interneurons after stress
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Perceptual processing during trauma, priming and the development of intrusive memories
Sündermann, O., Hauschildt, M., & Ehlers, A. (2013) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2012.10.001 · Cited by 53 · see citing works
The Roles of Noradrenergic and Glucocorticoid Activation in the Development of Intrusive Memories
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Hallucinations in posttraumatic stress disorder: insights from predictive coding
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Posttraumatic Stress Disorder and Autobiographical Memories in Everyday Life
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Imagery-enhanced cognitive behavioural group therapy for social anxiety disorder: A pilot study
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The role of estrogen in intrusive memories
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Intrusive memories of trauma in the laboratory: Methodological developments and future directions
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A Theoretical Framework for Understanding Recovered Memory Experiences
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Self-citationChoking under Pressure: Degrading Flashforwards Related to Performance Anxiety
Engelhard, I. M., Sijbrandij, M., van den Hout, M. A., Rutherford, N. M., Rahim, H. F., & Kocak, F. (2012) · Journal of Experimental Psychopathology · doi:10.5127/jep.024111 · Cited by 31 · see citing works
Ball, S. C., & Brewin, C. R. (2012) · Journal of Experimental Psychopathology · doi:10.5127/jep.019511 · Cited by 32 · see citing works
Self-citationIs romantic partner betrayal a form of traumatic experience? A qualitative study
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The role of stress during memory reactivation on intrusive memories
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Future-Oriented Positive Mental Imagery Reduces Anxiety for Exposure to Public Speaking
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Bosch, M., & Arntz, A. (2023) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2021.08.001 · Cited by 24 · see citing works
Contextual memory, psychosis-proneness, and the experience of intrusive imagery
Glazer, D. A., Mason, O., King, J. A., & Brewin, C. R. (2013) · Cognition & Emotion · doi:10.1080/02699931.2012.683850 · Cited by 18 · see citing works
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Biomarkers of post-traumatic stress disorder from emotional trauma: A systematic review
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A prospective examination of risk factors in the development of intrusions following a trauma analog
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Gender, personality, and involuntary autobiographical memory
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Systematic review on the treatment of emotional abuse victimization in women by an intimate partner
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Mental imagery and anxiety toward death in adolescents
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“Finally, there is increasing recognition that intrusive MI is important in the development and maintenance of anxiety disorders (Brewin et al., 2010) but has only been explored in autistic individuals across two studies.”
Influential
- Authors
- Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N.
- Affiliations
- University College London (GB)
- UCL Queen Square Institute of Neurology (GB)
- Venue
- Psychological Review
- Published
- 2010-01
- Volume
- 117
- Issue
- 1
- Pages
- 210-232
- ISSN
- 0033-295X (ISSN-L)
- 1939-1471
- PMC
- PMC2834572
- OpenAlex
- W2127046953
- Cited by
- 1,226
- References
- 218
- Citations by year
- 2026: 84 · 2025: 96 · 2024: 99 · 2023: 89 · 2022: 105 · 2021: 88 · 2020: 83 · 2019: 79 · 2018: 70 · 2017: 71 · 2016: 57 · 2015: 80 · 2014: 60 · 2013: 58 · 2012: 53
- FWCI
- 56.43
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Psychological Review (publishedVersion, other-oa)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- ORCA Online Research @Cardiff (Cardiff University) (submittedVersion)
- Funders
- Wellcome Trust
- Medical Research Council
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Life Sciences › Neuroscience › Cognitive Neuroscience › Memory Processes and Influences
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- intrusive images, visual memory, post-traumatic stress disorder, anxiety disorders, depression, eating disorders, psychosis, context representation, visuospatial working memory, medial prefrontal cortex, medial temporal lobe, psychotherapy
- MeSH terms
- Anxiety Disorders, Brain, Cognition Disorders, Depressive Disorder, Humans, Imagination, Nerve Net, Neuropsychological Tests, Temporal Lobe
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