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1.
Tenore, Katia; Mancini, Alessandra; Luppino, Olga Ines; Mancini, Francesco
Group Imagery Rescripting on Childhood Memories Delivered via Telehealth: A Preliminary Study Journal Article
In: Frontiers in Psychiatry, 2022.
Abstract | Links | BibTeX | Tag: affective state, autobiographical memories, emotional needs, imagery rescripting, maladaptive beliefs, memory realism, needs’ satisfaction
@article{Tenore2022,
title = {Group Imagery Rescripting on Childhood Memories Delivered via Telehealth: A Preliminary Study},
author = {Katia Tenore and Alessandra Mancini and Olga Ines Luppino and Francesco Mancini},
editor = {Frontiers in Psychiatry},
url = {https://apc.it/2022-mancini-group-imagery-rescripting/},
doi = {https://doi.org/10.3389/fpsyt.2022.862289},
year = {2022},
date = {2022-06-23},
journal = {Frontiers in Psychiatry},
abstract = {Background: Imagery Rescripting (ImR) has proved to be effective in the treatment of different mental disorders as an integral part of broader clinical protocols or as a standalone technique. ImR has also been successfully incorporated as part of group Schema Therapy treatment; however, to the best of our knowledge, it has never been assessed as a standalone technique in a group setting.
Aim: In this study, we focused on ImR delivered via telehealth in groups and we aimed to assess whether group ImR is effective in responding to basic emotional needs, in changing participants’ affective state, and in reducing dysfunctional beliefs. We also wanted to assess whether memory realism is associated with a greater effectiveness of the technique.
Methods: A total of 52 participants were presented with 3 ImR sessions on childhood memories related to the current dysfunctional belief that elicited more suffering.
Results: The technique was effective in facilitating the retrieval of a memory in almost the entire sample (in the range of 92.3–100%). Overall, memory realism values (level of vividness, ability to immerse, and participants’ distance from the images) were high in all three sessions. Almost all participants were reported having their needs met during ImR (89.7%). Importantly, need satisfaction was associated with the ability to immerse in the image. In addition, the intensity of the dysfunctional belief decreased significantly from pre-test to Session 3. The technique also changed the affective state, reducing arousal. Importantly, we also observed a general reduction in shame levels from the first to the third session.
Conclusion: A telehealth delivered ImR group intervention on childhood memories provides cognitive and emotional improvement. Along with the ability to satisfy the patient’s basic emotional needs, the technique seems to be effective in modifying maladaptive beliefs encapsulated in memory.},
keywords = {affective state, autobiographical memories, emotional needs, imagery rescripting, maladaptive beliefs, memory realism, needs’ satisfaction},
pubstate = {published},
tppubtype = {article}
}
Background: Imagery Rescripting (ImR) has proved to be effective in the treatment of different mental disorders as an integral part of broader clinical protocols or as a standalone technique. ImR has also been successfully incorporated as part of group Schema Therapy treatment; however, to the best of our knowledge, it has never been assessed as a standalone technique in a group setting.
Aim: In this study, we focused on ImR delivered via telehealth in groups and we aimed to assess whether group ImR is effective in responding to basic emotional needs, in changing participants’ affective state, and in reducing dysfunctional beliefs. We also wanted to assess whether memory realism is associated with a greater effectiveness of the technique.
Methods: A total of 52 participants were presented with 3 ImR sessions on childhood memories related to the current dysfunctional belief that elicited more suffering.
Results: The technique was effective in facilitating the retrieval of a memory in almost the entire sample (in the range of 92.3–100%). Overall, memory realism values (level of vividness, ability to immerse, and participants’ distance from the images) were high in all three sessions. Almost all participants were reported having their needs met during ImR (89.7%). Importantly, need satisfaction was associated with the ability to immerse in the image. In addition, the intensity of the dysfunctional belief decreased significantly from pre-test to Session 3. The technique also changed the affective state, reducing arousal. Importantly, we also observed a general reduction in shame levels from the first to the third session.
Conclusion: A telehealth delivered ImR group intervention on childhood memories provides cognitive and emotional improvement. Along with the ability to satisfy the patient’s basic emotional needs, the technique seems to be effective in modifying maladaptive beliefs encapsulated in memory.
Aim: In this study, we focused on ImR delivered via telehealth in groups and we aimed to assess whether group ImR is effective in responding to basic emotional needs, in changing participants’ affective state, and in reducing dysfunctional beliefs. We also wanted to assess whether memory realism is associated with a greater effectiveness of the technique.
Methods: A total of 52 participants were presented with 3 ImR sessions on childhood memories related to the current dysfunctional belief that elicited more suffering.
Results: The technique was effective in facilitating the retrieval of a memory in almost the entire sample (in the range of 92.3–100%). Overall, memory realism values (level of vividness, ability to immerse, and participants’ distance from the images) were high in all three sessions. Almost all participants were reported having their needs met during ImR (89.7%). Importantly, need satisfaction was associated with the ability to immerse in the image. In addition, the intensity of the dysfunctional belief decreased significantly from pre-test to Session 3. The technique also changed the affective state, reducing arousal. Importantly, we also observed a general reduction in shame levels from the first to the third session.
Conclusion: A telehealth delivered ImR group intervention on childhood memories provides cognitive and emotional improvement. Along with the ability to satisfy the patient’s basic emotional needs, the technique seems to be effective in modifying maladaptive beliefs encapsulated in memory.
2.
Albanese, Marzia; Liotti, Marianna; Cornacchia, Lucia; Mancini, Francesco
Nightmare Rescripting: Using Imagery Techniques to Treat Sleep Disturbances in Post-traumatic Stress Disorder Journal Article
In: Frontiers in Psychiatry, 2022.
Abstract | Links | BibTeX | Tag: imagery rehearsal therapy, imagery rescripting, insomnia, nightmares, post-traumatic stress disorder, trauma
@article{Albanese2022,
title = {Nightmare Rescripting: Using Imagery Techniques to Treat Sleep Disturbances in Post-traumatic Stress Disorder},
author = {Marzia Albanese and Marianna Liotti and Lucia Cornacchia and Francesco Mancini},
url = {https://apc.it/2022-mancini-nightmare-rescripting/},
doi = {doi: 10.3389/fpsyt.2022.866144},
year = {2022},
date = {2022-04-04},
journal = {Frontiers in Psychiatry},
abstract = {Besides affecting 8% of the general population, nightmares are one of the most frequent symptoms of traumatized individuals. This can be a significant factor in the treatment of post-traumatic disorders; indeed, several studies demonstrated its strong predictive and prognostic value. Sleep disorders, nightmares in particular, could be very distressing for individuals and need targeted interventions, especially if they are associated with a PTSD diagnosis. To date, the best technique for the treatment of traumatic sleep disturbances seems to be Imagery Rehearsal Therapy (IRT), an empirically supported method. Through a review of the literature on this matter, this article aims to outline the incidence and consequences of nightmares in PTSD, illustrate how IRT could prove useful in their treatment, and investigate its clinical applications.
Post-traumatic stress disorder (PTSD) is a mental health condition, which in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5; (1)] has been included in a new category, “Trauma and Stressor Related Disorders.” PTSD is characterized by the appearance of a wide array of symptoms after experiencing “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence” [(1), p. 271], in the following ways: direct exposure to the event; witnessing the event; learning that a close one was exposed to a traumatic event; indirect exposure to details of the trauma.
PTSD diagnosis was added–not without many controversies–only in the third edition of the DSM [DSM-III; (2)], after noticing the development of post-traumatic symptoms among many veteran soldiers. However, it is possible to identify some descriptions ascribable to this disorder already at the beginning of the twentieth century, when many authors spoke of “war neurosis,” “soldier's heart,” and “shell shock” to describe the physio-psychological consequences of being exposed to war situations [for a historical overview, see (3)]. Shortly after the diagnosis of PTSD was introduced in the DSM, clinicians began to notice that there were other individuals–victims of sexual or physical abuse, for example–whose symptoms largely corresponded with those observed in soldiers. Today we know that the traumatic events that can give rise to PTSD are numerous and of various kinds. They produce lasting effects, which the DSM-5 describes as follows, dividing them into four clusters:
1) Re-experience of the traumatic event (intrusion symptoms) through distressing memories, dreams and nightmares, flashbacks, and dissociative reactions.
2) Avoidance of stimuli associated with the traumatic event.
3) Negative alterations in cognition and mood (e.g., amnesia, negative beliefs and expectations, distorted cognitions, feelings of detachment).
4) Marked alterations in arousal and reactivity (e.g., irritability, self-destructive behaviors, hypervigilance, difficulties in concentrating, sleep disturbances).
According to the DSM-5, in the United States PTSD affects ~5% of men and 10% of women (1). In Italy, epidemiological studies show that about 56.1% of the general population is exposed to at least one traumatic event (with an average of 4 traumatic events experienced during the lifespan); the risk of experiencing PTSD following exposure to a traumatic event(s) is assessed to be between 0.8 and 12.2% (4). These data highlight the significance of a better understanding of the complex symptoms that are often associated with PTSD to develop targeted and effective intervention techniques.},
keywords = {imagery rehearsal therapy, imagery rescripting, insomnia, nightmares, post-traumatic stress disorder, trauma},
pubstate = {published},
tppubtype = {article}
}
Besides affecting 8% of the general population, nightmares are one of the most frequent symptoms of traumatized individuals. This can be a significant factor in the treatment of post-traumatic disorders; indeed, several studies demonstrated its strong predictive and prognostic value. Sleep disorders, nightmares in particular, could be very distressing for individuals and need targeted interventions, especially if they are associated with a PTSD diagnosis. To date, the best technique for the treatment of traumatic sleep disturbances seems to be Imagery Rehearsal Therapy (IRT), an empirically supported method. Through a review of the literature on this matter, this article aims to outline the incidence and consequences of nightmares in PTSD, illustrate how IRT could prove useful in their treatment, and investigate its clinical applications.
Post-traumatic stress disorder (PTSD) is a mental health condition, which in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5; (1)] has been included in a new category, “Trauma and Stressor Related Disorders.” PTSD is characterized by the appearance of a wide array of symptoms after experiencing “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence” [(1), p. 271], in the following ways: direct exposure to the event; witnessing the event; learning that a close one was exposed to a traumatic event; indirect exposure to details of the trauma.
PTSD diagnosis was added–not without many controversies–only in the third edition of the DSM [DSM-III; (2)], after noticing the development of post-traumatic symptoms among many veteran soldiers. However, it is possible to identify some descriptions ascribable to this disorder already at the beginning of the twentieth century, when many authors spoke of “war neurosis,” “soldier's heart,” and “shell shock” to describe the physio-psychological consequences of being exposed to war situations [for a historical overview, see (3)]. Shortly after the diagnosis of PTSD was introduced in the DSM, clinicians began to notice that there were other individuals–victims of sexual or physical abuse, for example–whose symptoms largely corresponded with those observed in soldiers. Today we know that the traumatic events that can give rise to PTSD are numerous and of various kinds. They produce lasting effects, which the DSM-5 describes as follows, dividing them into four clusters:
1) Re-experience of the traumatic event (intrusion symptoms) through distressing memories, dreams and nightmares, flashbacks, and dissociative reactions.
2) Avoidance of stimuli associated with the traumatic event.
3) Negative alterations in cognition and mood (e.g., amnesia, negative beliefs and expectations, distorted cognitions, feelings of detachment).
4) Marked alterations in arousal and reactivity (e.g., irritability, self-destructive behaviors, hypervigilance, difficulties in concentrating, sleep disturbances).
According to the DSM-5, in the United States PTSD affects ~5% of men and 10% of women (1). In Italy, epidemiological studies show that about 56.1% of the general population is exposed to at least one traumatic event (with an average of 4 traumatic events experienced during the lifespan); the risk of experiencing PTSD following exposure to a traumatic event(s) is assessed to be between 0.8 and 12.2% (4). These data highlight the significance of a better understanding of the complex symptoms that are often associated with PTSD to develop targeted and effective intervention techniques.
Post-traumatic stress disorder (PTSD) is a mental health condition, which in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5; (1)] has been included in a new category, “Trauma and Stressor Related Disorders.” PTSD is characterized by the appearance of a wide array of symptoms after experiencing “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence” [(1), p. 271], in the following ways: direct exposure to the event; witnessing the event; learning that a close one was exposed to a traumatic event; indirect exposure to details of the trauma.
PTSD diagnosis was added–not without many controversies–only in the third edition of the DSM [DSM-III; (2)], after noticing the development of post-traumatic symptoms among many veteran soldiers. However, it is possible to identify some descriptions ascribable to this disorder already at the beginning of the twentieth century, when many authors spoke of “war neurosis,” “soldier's heart,” and “shell shock” to describe the physio-psychological consequences of being exposed to war situations [for a historical overview, see (3)]. Shortly after the diagnosis of PTSD was introduced in the DSM, clinicians began to notice that there were other individuals–victims of sexual or physical abuse, for example–whose symptoms largely corresponded with those observed in soldiers. Today we know that the traumatic events that can give rise to PTSD are numerous and of various kinds. They produce lasting effects, which the DSM-5 describes as follows, dividing them into four clusters:
1) Re-experience of the traumatic event (intrusion symptoms) through distressing memories, dreams and nightmares, flashbacks, and dissociative reactions.
2) Avoidance of stimuli associated with the traumatic event.
3) Negative alterations in cognition and mood (e.g., amnesia, negative beliefs and expectations, distorted cognitions, feelings of detachment).
4) Marked alterations in arousal and reactivity (e.g., irritability, self-destructive behaviors, hypervigilance, difficulties in concentrating, sleep disturbances).
According to the DSM-5, in the United States PTSD affects ~5% of men and 10% of women (1). In Italy, epidemiological studies show that about 56.1% of the general population is exposed to at least one traumatic event (with an average of 4 traumatic events experienced during the lifespan); the risk of experiencing PTSD following exposure to a traumatic event(s) is assessed to be between 0.8 and 12.2% (4). These data highlight the significance of a better understanding of the complex symptoms that are often associated with PTSD to develop targeted and effective intervention techniques.
3.
Tenore, Katia; Basile, Barbara; Cosentino, Teresa; Sanctis, Brunetto De; Fadda, Stefania; Femia, Giuseppe; Gragnani, Andrea; Luppino, Olga Ines; Pellegrini, Valerio; Perdighe, Claudia; Romano, Giuseppe; Saliani, Angelo Maria; Mancini, Francesco
Imagery Rescripting on Guilt-Inducing Memories in OCD: A Single Case Series Study Journal Article
In: Frontiers in Psychiatry, vol. 11, pp. 1018, 2020, ISSN: 1664-0640 .
Abstract | Links | BibTeX | Tag: criticism, guilt, imagery rescripting, memories, obsessive-compulsive disorder
@article{Tenore2020,
title = {Imagery Rescripting on Guilt-Inducing Memories in OCD: A Single Case Series Study},
author = {Katia Tenore and Barbara Basile and Teresa Cosentino and Brunetto De Sanctis and Stefania Fadda and Giuseppe Femia and Andrea Gragnani and Olga Ines Luppino and Valerio Pellegrini and Claudia Perdighe and Giuseppe Romano and Angelo Maria Saliani and Francesco Mancini},
editor = {Pedro Morgado, University of Minho, Portugal},
url = {https://apc.it/2020-mancini-imagery-rescripting-on-guilt-frontiers/},
doi = {10.3389/fpsyt.2020.543806 },
issn = {1664-0640 },
year = {2020},
date = {2020-09-30},
urldate = {2020-09-30},
journal = {Frontiers in Psychiatry},
volume = {11},
pages = {1018},
abstract = {Background and objectives: Criticism is thought to play an important role in obsessive-compulsive disorder (OCD), and obsessive behaviors have been considered as childhood strategies to avoid criticism. Often, patients with OCD report memories characterized by guilt-inducing reproaches. Starting from these assumptions, the aim of this study is to test whether intervening in memories of guilt-inducing reproaches can reduce current OCD symptoms. The emotional valence of painful memories may be modified through imagery rescripting (ImRs), an experiential technique that has shown promising results.
Methods: After monitoring a baseline of symptoms, 18 OCD patients underwent three sessions of ImRs, followed by monitoring for up to 3 months. Indexes of OCD, depression, anxiety, disgust, and fear of guilt were collected.
Results: Patients reported a significant decrease in OCD symptoms. The mean value on the Yale−Brown Obsessive Compulsive Scale (Y-BOCS) changed from 25.94 to 14.11. At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS. Thirteen patients reported a reliable improvement, with ten reporting a clinically significant change (reliable change index = 9.94). Four reached the asymptomatic criterion. Clinically significant changes were not detected for depression and anxiety.
Conclusions: Our findings suggest that after ImRs intervention focusing on patients’ early experiences of guilt-inducing reproaches there were clinically significant changes in OCD symptomatology. The data support the role of ImRs in reducing OCD symptoms and the previous cognitive models of OCD, highlighting the role of guilt-related early life experiences in vulnerability to OCD.},
keywords = {criticism, guilt, imagery rescripting, memories, obsessive-compulsive disorder},
pubstate = {published},
tppubtype = {article}
}
Background and objectives: Criticism is thought to play an important role in obsessive-compulsive disorder (OCD), and obsessive behaviors have been considered as childhood strategies to avoid criticism. Often, patients with OCD report memories characterized by guilt-inducing reproaches. Starting from these assumptions, the aim of this study is to test whether intervening in memories of guilt-inducing reproaches can reduce current OCD symptoms. The emotional valence of painful memories may be modified through imagery rescripting (ImRs), an experiential technique that has shown promising results.
Methods: After monitoring a baseline of symptoms, 18 OCD patients underwent three sessions of ImRs, followed by monitoring for up to 3 months. Indexes of OCD, depression, anxiety, disgust, and fear of guilt were collected.
Results: Patients reported a significant decrease in OCD symptoms. The mean value on the Yale−Brown Obsessive Compulsive Scale (Y-BOCS) changed from 25.94 to 14.11. At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS. Thirteen patients reported a reliable improvement, with ten reporting a clinically significant change (reliable change index = 9.94). Four reached the asymptomatic criterion. Clinically significant changes were not detected for depression and anxiety.
Conclusions: Our findings suggest that after ImRs intervention focusing on patients’ early experiences of guilt-inducing reproaches there were clinically significant changes in OCD symptomatology. The data support the role of ImRs in reducing OCD symptoms and the previous cognitive models of OCD, highlighting the role of guilt-related early life experiences in vulnerability to OCD.
Methods: After monitoring a baseline of symptoms, 18 OCD patients underwent three sessions of ImRs, followed by monitoring for up to 3 months. Indexes of OCD, depression, anxiety, disgust, and fear of guilt were collected.
Results: Patients reported a significant decrease in OCD symptoms. The mean value on the Yale−Brown Obsessive Compulsive Scale (Y-BOCS) changed from 25.94 to 14.11. At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS. Thirteen patients reported a reliable improvement, with ten reporting a clinically significant change (reliable change index = 9.94). Four reached the asymptomatic criterion. Clinically significant changes were not detected for depression and anxiety.
Conclusions: Our findings suggest that after ImRs intervention focusing on patients’ early experiences of guilt-inducing reproaches there were clinically significant changes in OCD symptomatology. The data support the role of ImRs in reducing OCD symptoms and the previous cognitive models of OCD, highlighting the role of guilt-related early life experiences in vulnerability to OCD.
4.
Mancini, Alessandra; Mancini, Francesco
Rescripting Memory, Redefining the Self: A Meta-Emotional Perspective on the Hypothesized Mechanism(s) of Imagery Rescripting Journal Article
In: frontiers in Psychology, vol. 9, no 581, 2018.
Abstract | Links | BibTeX | Tag: autobiographical memory, emotional invalidation, imagery rescripting, meta-emotional problem, psychopathology, secondary problem, self-rapresentation
@article{Mancini2018,
title = {Rescripting Memory, Redefining the Self: A Meta-Emotional Perspective on the Hypothesized Mechanism(s) of Imagery Rescripting},
author = {Alessandra Mancini and Francesco Mancini},
editor = {frontiers in Psychology},
url = {https://apc.it/wp-content/uploads/2018/04/2018-Rescripting-Memory-Mancini-A.-Mancini-F..pdf},
doi = {doi: 10.3389/fpsyg.2018.00581},
year = {2018},
date = {2018-04-20},
journal = {frontiers in Psychology},
volume = {9},
number = {581},
abstract = {Imagery Rescripting (ImRs) is a therapeutic technique that aims to reduce the distress associated with negative memories of early aversive experiences. It consists of prompting patients to rescript the autobiographical memory in line with their unmet needs. In recent years, ImRs was found effective in reducing symptoms of disorders such as depression, social phobia, obsessive-compulsive disorder, post-traumatic stress disorder, and personality disorders. However, the cognitive mechanisms underlying such broad effectiveness are currently an object of debate.
Empirical evidence has shown that ImRs reduces the negative self-belief derived from aversive memories in different types of mental disorders. However, existing accounts are not very accurate in explaining how this change in self-belief occurs and therefore why ImRs is effective across psychopathologies. We propose that ImRs changes the semantic self-representation encapsulated in the aversive memory by reducing the meta-emotional problem (i.e., perceiving a negative emotion as problematic and unacceptable). Empirical evidence implicates the meta-emotional problem or “secondary problem” in the maintenance of different disorders and has shown that treating it leads to symptoms reduction. Here we hypothesize that: (i) ImRs as a standalone treatment may lead to a reduction of symptoms; negative self-belief and the meta-emotional problem; and (ii) the reduction of the meta-emotional problem might mediate the relation between symptoms and negative self-belief reduction. To test our hypothesis, we present an experimental procedure that could be used in future studies. We conclude discussing the existing theoretical frameworks that attempt to unravel the mechanisms that play a role in ImRs.
},
keywords = {autobiographical memory, emotional invalidation, imagery rescripting, meta-emotional problem, psychopathology, secondary problem, self-rapresentation},
pubstate = {published},
tppubtype = {article}
}
Imagery Rescripting (ImRs) is a therapeutic technique that aims to reduce the distress associated with negative memories of early aversive experiences. It consists of prompting patients to rescript the autobiographical memory in line with their unmet needs. In recent years, ImRs was found effective in reducing symptoms of disorders such as depression, social phobia, obsessive-compulsive disorder, post-traumatic stress disorder, and personality disorders. However, the cognitive mechanisms underlying such broad effectiveness are currently an object of debate.
Empirical evidence has shown that ImRs reduces the negative self-belief derived from aversive memories in different types of mental disorders. However, existing accounts are not very accurate in explaining how this change in self-belief occurs and therefore why ImRs is effective across psychopathologies. We propose that ImRs changes the semantic self-representation encapsulated in the aversive memory by reducing the meta-emotional problem (i.e., perceiving a negative emotion as problematic and unacceptable). Empirical evidence implicates the meta-emotional problem or “secondary problem” in the maintenance of different disorders and has shown that treating it leads to symptoms reduction. Here we hypothesize that: (i) ImRs as a standalone treatment may lead to a reduction of symptoms; negative self-belief and the meta-emotional problem; and (ii) the reduction of the meta-emotional problem might mediate the relation between symptoms and negative self-belief reduction. To test our hypothesis, we present an experimental procedure that could be used in future studies. We conclude discussing the existing theoretical frameworks that attempt to unravel the mechanisms that play a role in ImRs.
Empirical evidence has shown that ImRs reduces the negative self-belief derived from aversive memories in different types of mental disorders. However, existing accounts are not very accurate in explaining how this change in self-belief occurs and therefore why ImRs is effective across psychopathologies. We propose that ImRs changes the semantic self-representation encapsulated in the aversive memory by reducing the meta-emotional problem (i.e., perceiving a negative emotion as problematic and unacceptable). Empirical evidence implicates the meta-emotional problem or “secondary problem” in the maintenance of different disorders and has shown that treating it leads to symptoms reduction. Here we hypothesize that: (i) ImRs as a standalone treatment may lead to a reduction of symptoms; negative self-belief and the meta-emotional problem; and (ii) the reduction of the meta-emotional problem might mediate the relation between symptoms and negative self-belief reduction. To test our hypothesis, we present an experimental procedure that could be used in future studies. We conclude discussing the existing theoretical frameworks that attempt to unravel the mechanisms that play a role in ImRs.