Associations between characteristics of emotional mental imagery and auditory verbal hallucinations in individuals with psychosis spectrum disorders

Emotional Mental Imagery (eMI) may contribute to the development and persistence of auditory verbal hallucinations (AVHs), particularly through imagery appraisals. However, empirical evidence from large clinical samples is limited. The present study examined associations between seven characteristics of eMI (i.e., frequency, quality (liveliness, compellingness), and appraisals (encapsulated beliefs and metacognitions)) and AVH severity, exploring whether levels of depression and anxiety mediate this association. 107 individuals with subclinical (psychotic-like experiences) and clinical psychosis and current AVHs completed cross-sectional questionnaires on eMI, AVH severity, and the level of depression and anxiety. A multiple regression analysis was applied to test the association between seven aspects of eMI and AVH severity. Exploratory mediation analyses using the PROCESS macro for SPSS were applied. eMI characteristics were positively associated with the severity of AVHs in individuals with subclinical and clinical psychosis ( η 2 = 0.239, p < .001). Lower positive encapsulated beliefs ( η 2 = 0.072, p = .007) and higher negative metacognitions ( η 2 = 0.077, p = .005) were associated with more severe AVHs. The remaining five imagery characteristics failed to show significant associations with AVH severity. A significant indirect effect was found for negative metacognitions ( η 2 = 0.059, 99%CI 0.04, 0.36) on AVH severity via depression levels. Indirect pathways via anxiety did not reach statistical significance. Imagery appraisals seem important in relation to AVH severity across the psychosis spectrum, potentially via a mediating role of depression levels. Future studies are needed to further examine the underlying cognitive processes driving this association. • Most individuals included in the current study experienced distressing images linked to auditory verbal hallucinations. • Beyond maladaptive verbal thoughts, auditory verbal hallucinations are also associated with emotional mental imagery. • Imagery appraisals were associated with the severity of auditory verbal hallucinations. • Targeting imagery appraisals in cognitive behavioural therapy may enhance treatment efficacy.