Neural Mechanisms and Efficacy of Imagery Rescripting for Fear of Failure

Overview

This randomized controlled trial investigates the neural and psychophysiological mechanisms of Imagery Rescripting (ImRs) in individuals with high fear of failure. Participants (N=81, aged 21-34) were randomized to ImRs or an active control condition. The intervention targeted autobiographical memories of parental criticism across four sessions delivered within two weeks. Neuroimaging (fMRI), skin conductance, and self-report measures were assessed pre- and post-intervention (accordindly, TP1, TP5), with follow-ups at 3 and 6 months (accordingly, TP6, TP7). The primary aim was to examine whether ImRs reduces neural and subjective reactivity to autobiographical criticism memories and whether prediction error or memory reconsolidation disruption underlie therapeutic effects.

Fear of failure is a common psychological problem often associated with parental criticism and maladaptive perfectionism. Imagery Rescripting (ImRs) is a therapeutic technique derived from schema therapy that aims to modify distressing autobiographical memories by introducing corrective experiences in imagination. While ImRs has shown efficacy in anxiety and personality disorders, its underlying neural mechanisms remain insufficiently understood. This randomized controlled neuroimaging trial investigated the effects of ImRs on autobiographical memories of criticism in young adults with high levels of fear of failure. The study specifically examined whether therapeutic change is driven by disruption of memory reconsolidation or by prediction error mechanisms, both of which have been proposed as key pathways for updating maladaptive memories. Participants (N=81, aged 21-34) meeting inclusion criteria for high fear of failure (Performance Failure Appraisal Inventory ≥ 108) were randomized in a 2:1 ratio to either an ImRs intervention group or an active control group. Exclusion criteria included psychiatric disorders (e.g., PTSD, major depression), active pharmacotherapy, history of childhood abuse, and contraindications to MRI. All participants underwent two fMRI sessions (pre- and post-intervention), four intervention sessions within a two-week period, and follow-up assessments at 3 and 6 months. During fMRI, participants listened to personalized autobiographical scenarios: five involving parental criticism and five neutral ones. In the ImRs group, the criticism scenario was modified by introducing an imagined therapist figure who interrupted the critical interaction, addressed the child's needs, and suggested alternative positive outcomes. In the control group, participants engaged in a structurally similar neutral imagery task without therapeutic modification. Primary outcomes included changes in neural activation (BOLD fMRI) in fear-related brain regions (amygdala, thalamus, insula, ventromedial prefrontal cortex) when processing criticism versus neutral memories. Secondary outcomes included functional connectivity between prefrontal and subcortical regions, subjective ratings of arousal and emotions during scenarios, and questionnaire-based measures of fear of failure, perfectionism, and failure-related schemas. An exploratory outcome examined activation of the caudate nucleus during rescripting as a neural correlate of prediction error. The trial aimed to clarify whether ImRs reduces emotional reactivity at neural and subjective levels, and whether therapeutic effects are mediated reconsolidation-related neural changes or by prediction error. By combining personalized autobiographical stimuli, fMRI, psychophysiological measures, and longitudinal follow-up, the study provides novel insights into the mechanisms of memory-focused psychotherapy in individuals at risk of maladaptive perfectionism and fear of failure.