Targeting Negative *Flashforward* Imagery Using EMDR in Children and Adolescents with Social Anxiety Disorder: a Proof-of-Principle RCT

Social anxiety disorder (SAD) is a prevalent disorder in children and
adolescents, characterized by an increased fear of negative evaluation and
significant impairments in functioning. Treatment for SAD is currently less
effective than treatment for other anxiety disorders, pointing to room for
improvement of current SAD treatments. One factor that may provide a fruitful
pathway to intervene is mental imagery. It has been found that individuals with
SAD experience spontaneous negative images reflecting their main fears, which
have a negative impact on emotions and behaviour. Although children and
adolescents with (social) anxiety also mention experiencing imagery that is
upsetting, most studies on examining and targeting imagery have been conducted
in adults. As it is suggested that children are more prone to use
imagery(-based processing) and to experience (distressing) imagery than adults,
the potential value of identifying problematic imagery and incorporating
imagery in treatment with youths increases. In current study, we are interested
in further examining treatment components that target such negative
*flashforward* (FF) images of impending (or future) social catastrophes in
youth with SAD, thereby aiming to dampen their detrimental effects. One way to
target negative imagery is by using eye movement desensitization and
reprocessing (EMDR). After EMDR, imagery of (trauma) memories has repeatedly
been found to become less vivid and emotional, and possibly also (re)appraised
less negatively, leading to less anxiety and avoidance in daily life in both
adults and youths. The potential of using EMDR with imagery of future
catastrophic outcomes is demonstrated by a series of analogue intervention
studies in adults that found reductions in the vividness and emotionality of FF
images. To date, however, there are no studies on the use of EMDR with FF in
clinical samples with SAD. Nevertheless, the use of EMDR has been recommended
in the treatment of anxiety disorders by influential handbooks. In the Dutch
national multidisciplinary guidelines (i.e., Zorgstandaard Angstklachten en
angststoornissen), it is noticed that *EMDR is frequently used in the treatment
of anxiety disorders in routine clinical care*, but the treatment is not
recommended as an intervention of choice, given the relatively limited evidence
for its effectiveness for anxiety disorders. A structured evaluation of the
value of examining and targeting negative FF images in youths with SAD seems
very welcome and relevant.

The main objective is to evaluate the effectiveness of three sessions of EMDR
FF (targeting negative FF imagery related to youth*s most feared social
situations) in treating social anxiety (lowering anxiety and avoidance related
to those feared social situations) in children and adolescents with SAD. The
secondary objective is to examine whether changes in FF imagery characteristics
(lowering FF vividness and distress, and negative imagery appraisal) can
explain treatment effects (mediation).

The present study design is a parallel-group Randomized Controlled Trial (RCT)
with two conditions (EMDR FF versus a control group with no active treatment).
The study is intended as a *proof-of-principle*-study of the effects of EMDR FF
on anxiety and avoidance, and potential mediation of these effects by FF image
vividness, distress, and appraisal. After the first, assessment, participants
will be randomly assigned to one of the two conditions, with each condition
consisting of 25 participants. Participants in the EMDR FF group receive three
45-minute EMDR FF sessions, participants in the control group do not follow
these sessions. After the post-intervention assessment, youths continue to
receive regular treatment for their social anxiety, when applicable (e.g.
cognitive behavioural therapy (CBT), when they are next on the waitlist) and
complete the final follow-up assessments during further regular care. The
assessments consist of questionnaires for both youths and parents, and an
imagery interview for youths.

The EMDR FF treatment consists of three 45-minute sessions, conducted over the
time of two weeks. The therapist follows a slightly adapted version of the EMDR
*flashforward procedure* each session, which also refers to the standard Dutch
EMDR protocol (de Jongh & ten Broeke, 2019). In each EMDR FF session,
participants are asked to recall and rate an image of feared future catastrophe
(i.e., FF) related to an anxious situation, as established previously in the
imagery interview at the pre-intervention assessment. The FF is *desensitized*
using EMDR following the flashforward procedure.

Treatment for SAD in youths is currently less effective than treatment for
other anxiety disorders. As late childhood and early adolescence have been
pointed out as the typical age of onset for social anxiety, improving treatment
in youths by incorporating mental imagery might improve further outcome and
costs. In the current research, we include children and adolescents as
participants, since research on imagery and imagery-based treatment in adults
might not be fully generalizable to youths. A potential risk of participation
could be the time burden (i.e., a total of 180 minutes for youths of completing
measures). Part of the questionnaires are administered during regular care, and
may therefore not be considered as additional burden. Completing the measures
may also involve distress experienced by the youths related to imagery about
negative events. However, asking about anxiety and future catastrophes is
common during both intake and regular treatment for anxiety disorders, and to
decrease potential risks, deliberate positive imagery and guidance by trained
EMDR therapists is included. Furthermore, the intervention that participants in
the EMDR-FF group receive (three 45-minute sessions of EMDR FF) is hypothesized
to be beneficial based on empirical and theoretical review, as well as frequent
use in clinical practice as an add-on to (social) anxiety and trauma treatment.
The participants in the no-contact control group have no intervention during
these two weeks. As, often, there is a waiting time for treatment at Accare of
around 4 weeks, this means that for most participants the first part of the
study is conducted during waiting time for regular treatment. Participation in
the current study entails no further impact on receiving regular care, since
all youths continue to receive regular treatment for their social anxiety after
the post-intervention assessment in Week 4, when applicable. It is thereby made
clear to youths and their parents that they can stop participation in the study
at any time, without consequences. Also, as all participants are in care at
Accare, when youths or parents are concerned about their functioning,
participants in both groups can contact their own therapist by regular means
and receive the care that is necessary. Some potential benefits can be
anticipated. First, by participating in the study, participants are able to get
insight in their own imagery, which may not only be useful for their own
further CBT treatment (when applicable), but also for increasing insight in
imagery of socially anxious youth in general. Also, participating in the study
provides preliminary information on the value of using EMDR with negative FF
imagery. This in an important first step that could potentially improve
participants* own treatment outcome (for participants in the EMDR-FF group),
and eventually treatment of social anxiety in youth in general (by contributing
to research on this topic).