(Downloadable resources include an imagery assessment questionnaire available both as a PDF file and as a Word doc, a table to track changes during rescripting available as a PDF file and as a Word doc, a frequency/severity assessment scale also available both as a PDF file and as a Word doc, the text of the first & second of this blog sequence as a PDF file and as a Word doc, and the text of the third blog on treatment as a PDF file and as a Word doc) 

A couple of days ago I wrote a post on "The potential value of rescripting images in chronic pain & other distressed states like depression & anxiety: introduction".  In today's post I want to look at how we might identify & assess relevant images.  In Clare Philips' research study "Imagery and pain: The prevalence, characteristics, and potency of imagery associated with pain" she wrote "the characteristics of the Index image were assessed (frequency, similarity, persistence and clarity of image). Once the Index image had been fully described, respondents were asked about image meaning: What does this picture mean to you, your future or your life?"  Links between the images and actual memories were discussed.  Then participants took part in a "Voluntary Image Exposure procedure" where they were asked to form the image and then answer questions about them. They could do so with eyes open or closed. All formed their index image within seconds of the request, and were able to answer questions about image characteristics as well as their emotions, pain and behavioural response to the image, using "analogue scales ... from 0 (none) to 10 (maximum levels) of anxiety, sadness, anger, happiness, and calm. The cognitive scales of believed threat and physical and/or emotional fragility (defined as easily broken, weak) were assessed using analogue scales from 0 (no belief) to 10 (maximum belief/conviction).  The pain scale used was from 0 (no pain) to 10 (unendurable pain)."  Philips noted that "In response to an open-ended question, participants found it difficult to articulate a single or predominant meaning of their index image. Few had considered meaning prior to the question being asked by the investigator. The result was frequently a number of answers with respect to image meaning.

Presenting them with a discrete number of meaning categories to choose from also had limitations. Often more than one category was chosen, as in the following example. "I see myself sitting alone in my wheelchair. I am old and unable to care for myself ".  When asked about the meaning of her image, the 35-year old women replied it meant she would be a burden to her children in the future. Presented with a number of meaning categories, she chose five: future catastrophe, physical disability, absence of control, unhappiness, and dependence.  In addition to the open-ended and categorical approaches to defining image meaning, the experimenter classified participant responses into the predominant categories. Nearly 1/4 (23%) gave negative self-appraisals (i.e. "I am a loser"). A future catastrophe was described by 28.2% and a past catastrophe (accident or other past trauma) was described by 12.8% ... The relation of the image to past memories was assessed using categories: 34.1% reported the image was connected to their memory of the causative accident that had led to their pain problem; 18.2% felt the image came from memories of family worries, and 13.6% identified memories of their work situation. As can be seen in the examples below, this classification does not do justice to the complexities and details of many of the reported images.

- "I see my mother needing me. She is upset and I can not help. She can't get out of a dark dungeon." (classified by participant as: Memories of family concern/worries).

- "My body is crying, and I feel it. I can't move and it is solid and tight. Others look at me wanting to help ... their eyes look at me." (classified by participant as: Memories - idiosyncratic).

- "I see the ugly faces of the irresponsible management ... the unethical things they are doing ... the threats and intimidation. The pictures open like an umbrella". (classified by participant as: Memories of work situation).

- "I see an old woman with a cane ... curved over. I look under her hood - it is ME!" (image of a women in her 20s) (classified by participant as Memories - idiosyncratic)."

Philips went on to write "The causal event is not always present in the image. The past event may have occurred sometime before, even a memory from childhood 40 years earlier.  One catastrophic event (causal accident) appears not infrequently to lead to memories/images of a previous trauma event.  Catastrophic consequences (not experienced by the participant) may be elaborated in the memory of the causative accident.  Catastrophic future worries may also be visualized ... In summary, imagery was found to be a common though even if "unobserved" form of cognition in these pain sufferers. When assessing their index image, participants reported frequent, clear, brief and unchanging content. The appraisal of the image meaning proved complex. Participants appeared perplexed, and endorsed a number of meaning categories. However, categorization of meaning statements showed that the majority were focused upon negative self-appraisal and predicted catastrophe."

Using simple 0 (0 = none) to 10 (10 = maximum levels) scales, assessment was made of changes in mood and pain brought on when the pain sufferers visualised their most upsetting image.  The effects were dramatic on all the measured emotions and on the pain too.  So average increases in anxiety, sadness & anger were 48%, 68% & 103% respectively.  Average decreases in happiness & calm were 66% & 46%.  And in the few brief minutes of stationary visualisation, pain levels increased by an average of 25%.  Although people suffering from diagnosed posttraumatic stress disorder (PTSD) were referred to other, more specialised clinics, even in this Rehabilitation Centre based study, pain sufferers who scored higher on PTSD scales tended to report more frequent and more upsetting pain images.  Overall though, only about a third of all described images were actually of accidents leading to the pain.  

As a therapist my mind starts to whirl here.  Repetitive intrusive images appear to be much more common amongst chronic pain sufferers than I would have guessed.  How much is this also true for other distressed states like depression & anxiety?  Fascinatingly the majority of these pain-associated images do not seem to be about the accident that caused the problem, and the meanings linked to the images particularly involved "negative self-appraisal and predicted catastrophe."   Researchers have put in a lot of work on the relevance of images in depression & anxiety as well, but my strong impression is that the focus has been on traumatic experiences rather than the broader & more mixed picture highlighted by this pain research - see for example the 18 slides on "The importance of traumatic memories" that I put together for a talk I gave a few years ago on this subject and listed further down the "Good knowledge" page "Life review, traumatic memories & therapeutic writing".  The pain-linked images described in this research study are clearly therapeutically relevant.  The severe worsening in symptoms triggered by bringing the images to mind shows that they are not just irrelevant, peripheral aspects of the sufferers' experience.  In the next post I will describe Clare Philips' follow-on research demonstrating that altering the images powerfully alters the associated pain & distress.  It will be fascinating to explore the potential clinical relevance of these findings for chronic pain sufferers and for other distressed states too.  To help with this process I have put together an imagery assessment questionnaire (available both as a PDF file and as a Word doc), and a frequency/severity assessment scale (also available both as a PDF file and as a Word doc).     

For the next post, click on "The potential value of rescripting images in chronic pain & other distressed states like depression & anxiety: treatment".