A high percentage of chronic pain sufferers seem to be affected by recurrent imagery that is linked to and aggravates their pain.  Often the imagery's occurrence only emerges with careful questioning.  "Rescripting" these images is associated with impressive short term improvements in pain and distress.  What's exciting is the potential for longer term benefits from this kind of rescripting approach ... not only for chronic pain sufferers but also for people suffering from other persistent distressing states like depression and anxiety.

Clare Philips, a researcher at the Rehabilitation Centre in Richmond, Canada, has written a couple of fascinating research papers on this topic.  The first - published in 2011 - is entitled "Imagery and pain: The prevalence, characteristics, and potency of imagery associated with pain".  Its abstract reads "The images of 59 pain sufferers were assessed by means of a semi-structured interview. The emotional, cognitive, behavioural, and pain-inducing properties (potency) of their index images were assessed by an image induction procedure and self-report scales of anxiety, depression and trauma symptoms.  Results: The results showed a remarkably high incidence of images in pain sufferers, with 78% of participants reporting one or more repetitive images when in pain. Exposure to their most powerful/distressing image (Index image) resulted in significant increases in negative emotions, negative cognitive appraisals, and in pain levels. In a sub-group of sufferers with significant levels of trauma symptoms, the index images elicited significantly higher levels of emotion and pain increment than did those respondents in a low/no trauma group.  Conclusion: It was concluded that imagery is a prevalent, often "unobserved" but potent cognition in pain sufferers. The implications for CBT approaches to chronic pain, including image rescripting, are considered."

The pain sufferers assessed in this trial had all been referred to an 8 to 10 week programme at a Canadian Occupational Rehabilitation Centre through a Workers Compensation Board or insurance companies.  Philips commented "These sources refer only those people whom they feel will be returning to work after the program of supervised exercise and work-hardening. People with psychological problems (i.e. alcoholism, drug dependence, post-traumatic stress disorder, anxiety disorders) are referred to (other) specialized clinics."  So these patients, described by Philips below, were probably troubled by fewer comorbid psychological difficulties than many other groups of pain sufferers.  The research paper noted "The mean age of the participants was 45.6 (SD = 10.5) ... Most (88%) reported pain onset directly linked to a work-related accident, while 8.5% reported a motor vehicle accident. Average pain levels in the preceding 2 weeks (0-10 scale, where 10 = unendurable pain) were estimated by participants as 4.99 (SD = 1.67) and peak pain was estimated at 7.1 (SD = 2.1). The chronicity of their current pain problem was 37.4 weeks (SD = 2.97) ... Litigation was ongoing for only 5 of 59 participants."  The trauma history is interesting here, although it seems that those diagnosed as suffering from full PTSD were referred elsewhere.

It's well worth noting that Philips found she needed to be careful how she asked about pain associated imagery.  Some patients apparently became upset by these questions, feeling that the researcher was suggesting that they were in some way "imagining" their pain.  Philips wrote "To clarify the presence and content of any mental imagery, two open-ended questions were used. (The first question was used merely as a smooth transition into an enquiry about imagery.  The replies to this first question were not analyzed in this study.)  Q1: People experiencing pain think about many things. Tell me about some of the thoughts that keep coming back into your mind when you are in pain. Once their thoughts had been noted, the key question for this study was asked.  Q2: Do you also sometimes see picture thoughts? Thoughts which you picture to yourself when you are in pain? . . . that pop in to your mind when you are in pain? [An alternative question was used if the participants appeared not to understand the initial question: "Do you visualize your thoughts when in pain? Tell me some of your picture thoughts associated with pain that pop in to your mind when you are in pain."]"  Fascinatingly and probably importantly Philips found that "the pain thoughts were easily, quickly and unemotionally disclosed. The descriptions were general and without personal or idiosyncratic content (such as, when will I ever get better?). However, participants found the pain images difficult to articulate, and they were frequently accompanied by high levels of emotional response (i.e. tears, weeping, loss of eye-contact, flushing). The images were replete with personal details."  This dovetails very well with the general finding that imagery tends to be more linked with emotions than verbal thoughts are, and that this often makes imagery particularly important and helpful to work with therapeutically.

Apparently "Frequently the occurrence of imagery was not reported initially by participants but once the type of cognition was clarified (if necessary with an example: seeing a pink elephant), imagery reports were obtained. Participants were given time to consider the questions, as the phenomenon of image cognitions appeared novel to them. Few participants made a distinction between thoughts and mental images prior to the interview. Only visual images were investigated in this study.  Once the image(s) had been recorded, the participants were asked which of their images they felt was the most powerful/disturbing. This became the "Index" image that was used exclusively for the subsequent questions regarding characteristics and effects of the image."  I have a query here about selecting only one image to work with if one was using this approach as a treatment ... although I can see the sense in keeping things simple for the purposes of this exploratory research study.  In an earlier post about the treatment of posttraumatic stress disorder, I wrote "In a typical severe trauma there are likely to be several "hot spots" of particularly intense emotion.  These hot spots are crucial therapeutic targets as they are often sections of memory that are most disorganized and that are key sources of self-damaging misunderstanding." Philips noted that "The average number of images reported was 2.47 (range 1-6)."  In a therapeutic setting I would ask about the frequency of and level of distress associated with the different images and I would certainly consider rescripting all of the more severely upsetting images.  

In the second of this blog sequence on imagery rescripting for chronic pain & other distressed states like depression & anxiety, I will talk about identifying & assessing relevant images.