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

Aims To characterise the frequency, features and content of craving‐related mental imagery among people seeking treatment for substance use disorders (SUDs); examine within‐session change in self‐reported craving following imagery elicitation; and explore perceived links with autobiographical memory, behavioural, cognitive and emotional responses and imagery triggers. Design Mixed‐methods observational study incorporating a semi‐structured interview and repeated within‐session measurement of craving, with quantitative analyses and qualitative content analysis. Setting A single National Health Service adult community drug and alcohol treatment service in South London, United Kingdom. Participants Fifty‐five adults meeting Diagnostic and Statistical Manual of Mental Disorders , 5th Edition (DSM‐5) criteria for SUD were recruited between June and December 2019; 33 (60.0%) met criteria for more than one SUD. Measurements The interview assessed craving‐related imagery frequency, sensory and affective characteristics, content, autobiographical‐memory links, perceived responses and triggers. Craving was measured using the Craving Experience Questionnaire ̶ Strength (CEQ‐S11) at baseline, immediately after imagery elicitation and at the end of the interview. Results Fifty‐one participants (92.7%) reported craving‐related imagery. The predominant modality was visual in 49/51 (96.1%); among 50 participants with complete imagery data, 42 (84.0%) described recurrent imagery and 26 (52.0%) reported experiencing it daily. Forty‐seven (94.0%) perceived their image as representing an actual event or as strongly associated with autobiographical memory, usually an amalgamation of multiple memories. The 51 images were classified into five overlapping themes: stages of substance consumption (80.4%), the substance itself (84.3%), imagery features (94.1%), sensory experiences and activation (84.3%) and contextual or setting features (96.1%). Among 211 reported triggers, places (21.8%), people (19.9%) and internal moods (17.5%) were most frequent. Mean CEQ‐S11 scores were 39.50 at baseline, 48.70 immediately after imagery elicitation and 36.70 at interview end, with an overall effect of time, F(2, 100) = 5.03, P ‐value 0.008. Among participants with recurrent imagery, 31/42 (73.8%) reported often or always wanting to use the substance following the image, and 34/42 (81.0%) reported that the image often or always persisted until distraction or substance use. Summary In a mixed‐methods study of adults attending a community drug and alcohol treatment service, craving‐related mental imagery was commonly reported and was predominantly visual, often recurrent, closely linked to autobiographical memory and associated with perceived urges to use substances.