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Mental Imagery in Chronic Pain: An Access to Meaning Beyond Words
Abstract
Mental images are cognitions, which take the form of sensory experiences in the absence of a direct percept. Images can be opposed to verbal thoughts, i.e. cognitions in the form of words. From the perspective of clinical cognition, verbal thoughts and mental images are different phenomena, with mental images having tighter connections to emotion than verbal thoughts. Recently, cognitive psychology research has focused on spontaneous mental imagery, i.e. involuntary intrusions of often vivid mental images that appear in one’s mind. Spontaneous mental imagery is now viewed as an important part of psychopathological processes across psychological disorders, a potential emotional amplifier and a therapeutic target in its own right. Pain is a personal experience, so exploring and understanding the patient’s thoughts about pain might contribute to therapeutic success and favour personalized care. In the field, thoughts about pain have been mostly studied as verbal thoughts. Yet, a growing literature is investigating thoughts about pain in the form of imagery. Studying chronic pain patients’ mental imagery provides unique insight into their personal experience, integrating information about somatosensory perceptions, emotional experience and meanings of pain. The study of imagery in pain also gives insight into possible reinforcing mechanisms of pain, and a basis for a powerful, individualized therapeutic approach through different mental imagery therapy techniques. This chapter describes current knowledge about mental imagery as intrusive cognitions in the context of pain, considers the neuroscientific investigations that have been undertaken, and discusses the therapeutic potential it yields.
... Pain imagery may offer a unique insight into a patient's pain experience, as discussed by Berna in the first book of Meanings of Pain [37], and may provide a novel target for cognitive behavioural therapy [32] and other psychological therapies. ...
... The imagery themes we found align closely with those in the pain imagery literature, which tend to be relatively consistent across patients with various causes of chronic pain [31,32,35,36], as discussed by Berna [37]. Berna, Tracey and Holmes highlight that imagery can "incorporate symbolic or real elements of the patient's individual pain experience" [12]. ...
... ."), which promotes a shift in attention from pain [65]. Most often, a script is used with a standard image (for example, a meadow) [37]. Alternatively, positive imagery can be built in partnership with the patient [30], which aims to distract, relax, increase optimism, and/or improve emotions [37]. ...
Pain imagery is “like having a picture in your head [of your pain] which may include things you can imagine seeing, hearing or feeling.” Pain imagery may offer a unique insight into a patient’s pain experience. This chapter summarises findings from international pain imagery research in women with endometriosis-associated pain. Endometriosis is a chronic inflammatory condition associated with debilitating pain that affects 5–10% of women of reproductive age worldwide. Our international research has found that pain imagery is experienced by around half of women suffering from endometriosis-associated pain, and is associated with higher levels of catastrophising, depression, and anxiety. However, coping imagery is also reported, and prevalent, at 30%. Pain imagery in women with endometriosis falls into themes: sensory qualities of pain; loss of power or control; attack (by someone, “something,” or self); pathology or anatomy envisaged; past or future catastrophe; pain as an object; and abstract images. Imagery content may therefore reveal the meanings of pain or endometriosis to these women. This chapter explores pain imagery content and its personal significance to patients, both for women with endometriosis-associated pain and for patients with other chronic pain conditions. The chapter concludes by discussing the clinical application of imagery, with example patient cases to contextualise the practicalities and therapeutic potential of imagery techniques.
... Clinicians, argues Stewart, must strive to identify patients' metaphors in order to 'explore meaning, and to foster empathetic and therapeutic connections' (Stewart, 2016: 344). Using art, as Collen (2005) (Berna, 2016). Berna reports that therapeutic interventions may be helpful in the form of positive guided imagery for pain relief. ...
This work provides an exploration of the effects of sharing creative representations of life with chronic physical pain. Social media platforms (Facebook and WordPress) have been used to carry out the research, hosting two online galleries of creative works depicting life with chronic physical pain. Comments on the works, and discussions surrounding them, have been examined to show how different audiences respond to the works, according to whether or not they have pain. In keeping with the postmodern epistemology underpinning this research, issues of interpretation and multiple interpretations have been considered. In addition, responses have been assessed to consider how effective such works are in communicating the experience of living with this invisible and subjective condition. My role as a researcher with chronic physical pain is explored in relation to the use of reflexivity in carrying out the research. The conflict involved in seeking empathy and recognition of experiences living with pain, while balancing this with the desire to keep this personal experience private and the feeling that other people do not want to hear about the condition, is discussed in relation to the concept of public-private dualism. Issues regarding the elicitation of empathy and understanding with the creators’ experiences are considered in the light of the creative works. In addition, the benefits arising from sharing such works in online exhibitions are highlighted, demonstrating the potential for creative approaches to the expression of pain to facilitate the effective communication of the experience.
Available from: http://oro.open.ac.uk/71479/
... Meanings of Pain. 10 Opinions expressed are the authors' own. They do not necessarily reflect the view of the Royal College of Physicians of Edinburgh (CJG). ...
Based on Rapid Response: https://www.bmj.com/content/365/bmj.l4035/rr-0
Patients' expectations are important predictors of the outcome of analgesic treatments, as demonstrated predominantly in research on placebo effects. Three commonly investigated interventions that have been found to induce expectations (verbal suggestion, conditioning, and mental imagery) entail promising, brief, and easy to implement adjunctive procedures for optimizing the effectiveness of analgesic treatments. However, evidence for their efficacy stems mostly from research on experimentally evoked pain in healthy samples, and these findings might not be directly transferable to clinical populations. The current meta-analysis investigated the effects of these expectation inductions on patients' pain relief. Five bibliographic databases were systematically searched for studies that assessed the effects of brief verbal suggestion, conditioning, or imagery interventions on pain in clinical populations, with patients experiencing experimental, acute procedural, or chronic pain, compared to no treatment or control treatment. Of the 15955 studies retrieved, 30 met inclusion criteria, of which 27 provided sufficient data for quantitative analyses. Overall a medium sized effect of the interventions on patients' pain relief was observed (Hedges's g = 0.61, I2 = 73%), with varying effects of verbal suggestion (k = 18, g = 0.75), conditioning (always paired with verbal suggestion, k = 3, g = 0.65), and imagery (k = 6, g = 0.27). Subset analyses indicated medium to large effects on experimental and acute procedural pain, and small effects on chronic pain. In conclusion, patients' pain can be relieved with expectation interventions, particularly verbal suggestion for acute procedural pain was found to be effective.
See for full text: http://journals.lww.com/pain/Abstract/2016/06000/Relieving_patients__pain_with_expectation.2.aspx
Mental imagery research has weathered both disbelief of the phenomenon and inherent methodological limitations. Here we review recent behavioral, brain imaging, and clinical research that has reshaped our understanding of mental imagery. Research supports the claim that visual mental imagery is a depictive internal representation that functions like a weak form of perception. Brain imaging work has demonstrated that neural representations of mental and perceptual images resemble one another as early as the primary visual cortex (V1). Activity patterns in V1 encode mental images and perceptual images via a common set of low-level depictive visual features. Recent translational and clinical research reveals the pivotal role that imagery plays in many mental disorders and suggests how clinicians can utilize imagery in treatment. Recent research suggests that visual mental imagery functions as if it were a weak form of perception.Evidence suggests overlap between visual imagery and visual working memory - those with strong imagery tend to utilize it for mnemonic performance.Brain imaging work suggests that representations of perceived stimuli and mental images resemble one another as early as V1.Imagery plays a pivotal role in many mental disorders and clinicians can utilize imagery to treat such disorders.
Mental imagery has the potential to influence perception by directly altering sensory, cognitive, and affective brain activity associated with imagined content. While it is well established that mental imagery can both exacerbate and alleviate acute and chronic pain, it is currently unknown how imagery mechanisms regulate pain perception. For example, studies to date have been unable to determine whether imagery effects depend upon a general redirection of attention away from pain or related focused attentional mechanisms. To address these issues, we recorded subjective, behavioral and ERP responses using 64-channel EEG while healthy human participants applied a mental imagery strategy to decrease or increase pain sensations. When imagining a glove covering the forearm, participants reported decreased perceived intensity and unpleasantness, classified fewer high-intensity stimuli as painful, and showed a more conservative response bias. In contrast, when imagining a lesion on the forearm, participants reported increased pain intensity and unpleasantness, classified more low-intensity stimuli as painful, and displayed a more liberal response bias. Using a mass-univariate approach, we further showed differential modulation of the N2 potentials across conditions, with inhibition and facilitation respectively increasing and decreasing N2 amplitudes between 122 and 180 ms. Within this time window, source localization associated inhibiting vs. facilitating pain with neural activity in cortical regions involved in cognitive inhibitory control and in the retrieval of semantic information (i.e., right inferior frontal and temporal regions). In contrast, the main sources of neural activity associated with facilitating vs. inhibiting pain were identified in cortical regions typically implicated in salience processing and emotion regulation (i.e., left insular, inferior-middle frontal, supplementary motor and precentral regions). Overall, these findings suggest that the content of a mental image directly alters pain-related decision and evaluative processing to flexibly produce hypoalgesic and hyperalgesic outcomes.
Copyright © 2015. Published by Elsevier Inc.
Imagery Rescripting (ImRs) is a therapeutic technique addressing specific memories of earlier experiences associated with present problems. By imagining that the course of events is changed in a more desired direction, powerful therapeutic effects have been found. The interest in and applications of ImRs are quickly increasing. This review discusses clinical studies assessing effects of ImRs, as well as possible processes underlying ImRs, and laboratory studies examining these underlying processes. It is concluded that although research into ImRs is still in its infancy, and many studies have their methodological limitations, results are promising. Therefore a research agenda is sketched, suggesting the next steps in both clinical and fundamental research.
Therapy with mental images is prevalent in the field of chronic pain, and this has been the case for centuries. Yet few of the recent advances in the cognitive behavioural understanding of spontaneous (i.e. intrusive) mental imagery have been translated to this field. Such advances include imagery as a component of a psychopathological process, as an emotional amplifier and as a cognitive therapeutic target in its own right. Hence very little is known about the contents, prevalence and emotional impact of spontaneous mental imagery in the context of chronic pain. This article discusses the evidence in favour of spontaneous imagery being a potentially important part of patients' pain experience, and makes a case, based on neurophysiological findings, for imagery having an impact on pain perception. Furthermore, it presents how mental imagery has been used in the treatment of chronic pain. A case report illustrates further how spontaneous negative imagery linked to pain can be distressing, and how this might be addressed in therapy. Additionally, the case report demonstrates the spontaneous use of coping imagery, and raises a discussion of how this might be enhanced.
Via mental simulation, imagined events faithfully reproduce the neural and behavioral activities that accompany their actual occurrence. However, little is known about how fundamental characteristics of mental imagery-notably perspectives of self-shape neurocognitive processes. To address this issue, we used fMRI to explore the impact that vantage point exerts on the neural and behavioral correlates of imaginary sensory experiences (i.e., pain). Participants imagined painful scenarios from three distinct visual perspectives: first-person self (1PS), third-person self (3PS), and third-person other (3PO). Corroborating increased ratings of pain and embodiment, 1PS (cf. 3PS) simulations elicited greater activity in the right anterior insula, a brain area that supports interoceptive and emotional awareness. Additionally, 1PS simulations evoked greater activity in brain areas associated with visual imagery and the sense of body ownership. Interestingly, no differences were observed between 3PS and 3PO imagery. Taken together, these findings reveal the neural and behavioral correlates of visual perspective during mental simulation.
The variety of sensations conveyed by the English word pain tend to be described via expressions that refer to potential causes of bodily damage (e.g., stabbing, burning). Such expressions are used metaphorically when they convey pain experiences that do not directly result from physical damage (e.g., migraine pain). In this paper, I discuss psycholinguistic and neuroscientific research that suggests that these uses of metaphor may facilitate some form of embodied simulation of pain experiences on the part of listeners/readers, which may in turn provide the basis for an empathic response. I suggest that different kinds of metaphorical descriptions of pain vary in terms of their potential for eliciting a response involving embodied simulation, and in terms of the nature and intensity of the simulation they may elicit. I argue that the most relevant characteristics of metaphorical descriptions of pain in this respect are their level of detail, degree of creativity, and textual complexity.
The continuing absence of an identifiable physical cause for disorders such as chronic low back pain, atypical facial pain, or fibromyalgia, is a source of ongoing controversy and frustration among pain physicians and researchers. Aberrant cerebral activity is widely believed to be involved in such disorders, but formal demonstration of the brain independently generating painful experiences is lacking. Here we identify brain areas directly involved in the generation of pain using hypnotic suggestion to create an experience of pain in the absence of any noxious stimulus. In contrast with imagined pain, functional magnetic resonance imaging (fMRI) revealed significant changes during this hypnotically induced (HI) pain experience within the thalamus and anterior cingulate (ACC), insula, prefrontal, and parietal cortices. These findings compare well with the activation patterns during pain from nociceptive sources and provide the first direct experimental evidence in humans linking specific neural activity with the immediate generation of a pain experience.
Background: Emotional context may play a crucial role in movement production. According to simulation theories, emotional states affect motor systems. The aim of this study was to compare postural responses assessed by posturography and electromyography when subjects were instructed to imagine themselves in a painful or a non-painful situation.
Methods: Twenty-nine subjects (22.3 ± 3.7 years) participated in this study. While standing quietly on a posturographic platform, they were instructed to imagine themselves in a painful or non-painful situation. Displacement of the center of pressure (COP), leg muscle electromyographic activity, heart rate, and electrodermal activity were assessed in response to painful and non-painful situations.
Results: The anteroposterior path was shorter (p < 0.05) when subjects imagined themselves in a painful situation (M = 148.0 ± 33.4 mm) compared to a non-painful situation (158.2 ± 38.7 mm). Higher tibialis anterior (TA) activity (RMS-TA = 3.38 ± 1.95% vs. 3.24 ± 1.85%; p < 0.001) and higher variability of soleus (SO) activity (variation coefficient of RMS-SO = 13.5 ± 16.2% vs. M = 9.0 ± 7.2%; p < 0.05) were also observed in painful compared to non-painful situations. No significant changes were observed for other physiological data.
Conclusion: This study demonstrates that simulation of painful situations induces changes in postural control and leg muscle activation compared to non-painful situations, as increased stiffness was demonstrated in response to aversive pictures in accordance with previous results.
Implementing a recall paradigm without hypnosis, we use functional MRI (fMRI) to explore and compare nociceptive and centrally-driven pain experiences. We posit that a trace of a recent nociceptive event can be used to create sensory-re-experiencing of pain that can be qualified in terms of intensity and vividness. Fifteen healthy volunteers received three levels of thermal stimuli (warm, low pain and high pain) and subsequently were asked to recall and then rate this experience. Neuroimaging results reveal that recalling a previous sensory experience activates an extensive network of classical pain processing structures except the contralateral posterior insular cortex. Nociceptive-specific activation of this structure and the rated intensity difference between physical and recalled pain events allow us to investigate the link between the quality of the original nociceptive stimulus and the mental trace, as well as the differences between the accompanying neural responses. Additionally, by incorporating the behavioural ratings, we explored which brain regions were separately responsible for generating either an accurate or vivid recall of the physical experience. Together, these observations further our understanding of centrally-mediated pain experiences and pain memory as well as the potential relevance of these factors in the maintenance of chronic pain.
The relationship between imagery and mental representations induced through perception has been the subject of philosophical discussion since antiquity and of vigorous scientific debate in the last century. The relatively recent advent of functional neuroimaging has allowed neuroscientists to look for brain-based evidence for or against the argument that perceptual processes underlie mental imagery. Recent investigations of imagery in many new domains and the parallel development of new meta-analytic techniques now afford us a clearer picture of the relationship between the neural processes underlying imagery and perception, and indeed between imagery and other cognitive processes. This meta-analysis surveyed 65 studies investigating modality-specific imagery in auditory, tactile, motor, gustatory, olfactory, and three visual sub-domains: form, color and motion. Activation likelihood estimate (ALE) analyses of activation foci reported within- and across sensorimotor modalities were conducted. The results indicate that modality-specific imagery activations generally overlap with-but are not confined to-corresponding somatosensory processing and motor execution areas, and suggest that there is a core network of brain regions recruited during imagery, regardless of task. These findings have important implications for investigations of imagery and theories of cognitive processes, such as perceptually-based representational systems.
Previous research has demonstrated the efficacy of coping-skills training in stress inoculation for pain. The present study attempted to isolate the active ingredients of the coping-skills component, which consists of 3 categories of skills derived from J. Melzak's (1973) gate-control theory of pain: sensory discriminative (SD), motivational affective (MA), and cognitive evaluative (CE). 81 undergraduate females were pretested on the cold pressor, randomly assigned to 1 of 9 treatment conditions, and then posttested. Relaxation training (an SD procedure) produced increased tolerance, whereas distraction and imagery training (an MA procedure) resulted in higher threshold scores. Although the experimental conditions did not generate differential demand characteristics, 2 checks on independent variable manipulation revealed that SD skills were learned and employed, MA skills were already known but refined, and CE skills were largely ignored. (37 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The production of mental images involves processes that overlap with perception and the extent of this overlap may contribute to reality monitoring errors (i.e., images misremembered as actual events). We hypothesised that mental images would be more confused with having actually seen a pictured object than would alternative representations, such as verbal descriptions. We also investigated whether affective reactions to images were greater than to verbal descriptions, and whether emotionality was associated with more or less reality monitoring confusion. In two experiments signal detection analysis revealed that mental images were more likely to be confused with viewed pictures than were verbal descriptions. There was a general response bias to endorse all emotionally negative items, but accuracy of discrimination between imagery and viewed pictures was not significantly influenced by emotional valence. In a third experiment we found that accuracy of reality monitoring depended on encoding: images were more accurately discriminated from viewed pictures when rated for affect than for size. We conclude that mental images are both more emotionally arousing and more likely to be confused with real events than are verbal descriptions, although source accuracy for images varies according to how they are encoded.
Our previous review of the literature concluded that there is encouraging evidence that guided imagery alleviates musculoskeletal pain, but the value of guided imagery in the management of non-musculoskeletal pain remains uncertain.
The objective of this systematic review was to assess the effectiveness of guided imagery as a treatment option for non-musculoskeletal pain.
Six databases were searched from their inception to February 2011. Randomized clinical trials were considered if they investigated guided imagery in human patients with any type of non-musculoskeletal pain in any anatomical location and assessed pain as a primary outcome measure. Trials of motor imagery and hypnosis were excluded. The selection of studies, data extraction, and validation were performed independently by two reviewers.
Fifteen randomized clinical trials met the inclusion criteria. Their methodological quality was generally poor. Eleven trials found that guided imagery led to a significant reduction of non-musculoskeletal pain. Four studies found no change in non-musculoskeletal pain with guided imagery in comparison with progressive relaxation, standard care, or no treatment.
The evidence that guided imagery alleviates non-musculoskeletal pain is encouraging but remains inconclusive.
Ss in three experiments searched through an array of pictures or words for a target item that had been presented as a picture
or a word. In Experiments I and II, the pictures were line drawings of familiar objects and the words were their printed labels;
in Experiment III, the stimuli were photographs of the faces of famous people and their corresponding printed names. Search
times in Experiments I and II were consistently faster when the array items were pictures than when they were words, regardless
of the mode of the target items. Search was also faster with pictures than with words as targets when the search array also
consisted of pictures, but target mode had no consistent effect with words as array items. Experiment III yielded a completely
different pattern of results: Search time with names as targets and faces as search array items was significantly slower than
in the other three conditions, which did not differ from each other. Considered in relation to several theories, the results
are most consistent with a dual-coding interpretation. That is, items that are cognitively represented both verbally and as
nonverbal images can be searched and compared in either mode, depending on the demands of the task. The mode actually used
depends on whether the search must be conducted through an array of pictures or words.
Background:
Chronic pain patients often describe their pain in ways that suggest vivid mental images, with some reporting images relating to their pain. Despite these clinical observations, there are few studies describing the nature and consequences of these images. This study examined whether mental imagery of pain is associated with levels of reported distress, cognitions, disability or pain severity.
Method:
In a postal survey, 83 adult chronic pain patients indicated whether or not they experienced mental images of their pain. They also completed standardized measures of depression, anxiety, cognitions, disability and pain severity. Those reporting images were compared to those not reporting images on their responses to the other variables.
Results:
People with pain imagery reported significantly higher levels of anxiety, depression and catastrophizing than patients who did not report such images. No differences were found on measures of physical disability.
Discussion:
Mental images of pain appear to be associated with higher levels of anxiety, depression and catastrophizing. It is possible that these images play a role in maintaining such difficulties. For these patients, imagery may provide a route via which clinicians can work with patients to help them reinterpret or respond more flexibly to their pain.
To ascertain whether a small sample of patients with chronic pelvic pain experienced any pain-related cognitions in the form of mental images.
Ten women with chronic pelvic pain consecutively referred from a tertiary referral center by the physicians in charge of their treatment.
An interview was used to determine the presence, emotional valence, content, and impact of cognitions about pain in the form of mental images and verbal thoughts. The Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), Spontaneous Use of Imagery Scale (SUIS), and Hospital Anxiety and Depression Scale (HADS) were completed.
In a population of patients with a prolonged duration of pain and high distress, all patients reported experiencing cognitions about pain in the form of mental images. For each patient, the most significant image was both negative in valence and intrusive. The associated emotional-behavioral pattern could be described within a cognitive behavioral therapy framework. Eight patients also reported coping imagery.
Negative pain-related cognitions in the form of intrusive mental imagery were reported by women with chronic pelvic pain. Targeting such imagery has led to interesting treatment innovation in the emotional disorders. Thus, imagery, hitherto neglected in pain phenomenology, could provide a novel target for cognitive behavioral therapy in chronic pain. These exciting yet preliminary results require replication and extension in a broader population of patients with chronic pain.
According to the dual representation theory of PTSD, intrusive trauma images and intrusive verbal thoughts are produced by separate memory systems. In a previous article it was shown that after watching an aversive film, participants in non-movement conditions reported more intrusive images than participants in a free-to-move control condition (Hagenaars, Van Minnen, Holmes, Brewin, & Hoogduin, 2008). The present study investigates whether the experimental conditions of the Hagenaars et al. study had a different effect on intrusive thoughts than on intrusive images. Experiment 2 further investigated the image-thoughts distinction by manipulating stimulus valence (trauma film versus neutral film) and assessing the subsequent development of intrusive images and thoughts. In addition, both experiments studied the impact of peri-traumatic emotions on subsequent intrusive images and thoughts frequency across conditions. Results showed that experimental manipulations (non-movement and trauma film) caused higher levels of intrusive images relative to control conditions (free movement and neutral film) but they did not affect intrusive thoughts. Peri-traumatic anxiety and horror were associated with subsequent higher levels of intrusive images, but not intrusive thoughts. Correlations were inconclusive for anger and sadness. The results suggest intrusive images and thoughts can be manipulated independently and as such can be considered different phenomena.
Mental imagery has been considered relevant to psychopathology due to its supposed special relationship with emotion, although evidence for this assumption has been conspicuously lacking. The present review is divided into four main sections: (1) First, we review evidence that imagery can evoke emotion in at least three ways: a direct influence on emotional systems in the brain that are responsive to sensory signals; overlap between processes involved in mental imagery and perception which can lead to responding "as if" to real emotion-arousing events; and the capacity of images to make contact with memories for emotional episodes in the past. (2) Second, we describe new evidence confirming that imagery does indeed evoke greater emotional responses than verbal representation, although the extent of emotional response depends on the image perspective adopted. (3) Third, a heuristic model is presented that contrasts the generation of language-based representations with imagery and offers an account of their differing effects on emotion, beliefs and behavior. (4) Finally, based on the foregoing review, we discuss the role of imagery in maintaining emotional disorders, and its uses in psychological treatment.
To ascertain the influence of images depicting different qualities of pain on unselected outpatient pain clinic consultations.
A resource of 64 colour images depicting different qualities of pain was given to patients in clinic waiting rooms, which they could take into consultations and use as a focus for discussion with clinicians. A questionnaire enquiring into the value of such images was completed at the end of each consultation separately and anonymously by clinicians and patients. The questionnaires carried identifiers that allowed pairing in the analysis, which was undertaken qualitatively and thematically.
Forty-four percent (20/45) of Pain Clinics declaring an interest in taking part in the study returned 64/80 (80%) pairs of questionnaires. Eighty-six percent (54) of patients related their pain to at least one image during their consultation and 67% found discussion of the images facilitated dialogue. Eighty two percent of clinicians reported improved communication as a result of the images with 78% reporting degrees of greater understanding of patients' pain. The four main themes identified in analysis of questionnaire data included: a broadening of verbal dialogue; a sense of improved clinician-patient relationship; limitations of setting (time); a variety of practical benefits for future use. The most prominent effect was that the images appeared to encourage discussion of the affective elements of the pain experience.
The results suggest that introducing a focus of images of pain into unselected pain consultations can facilitate discussion and lead to more fruitful dialogue between patients and clinicians.
Previous studies suggested that areas of the pain matrix of the human brain are recruited by the processing of pain-related environmental cues such as pain-related pictures or descriptors of pain. However, it is still sketchy whether those activations are specific to the pain-relevance of the stimuli or simply reflect a general effect of negative valence or increased arousal. The present study investigates the neural mechanisms underlying the processing of pain-related, negative, positive, and neutral words. Pain-related words were matched to negative words regarding valence and arousal, and to positive words regarding arousal. Sixteen healthy subjects were scanned during two tasks, imagination and distraction, using functional MRI. When subjects were instructed to image a situation associated with the word presented (imagination task), we found increased activation within dorsolateral prefrontal cortex (DLPFC), inferior patietal gyri (IPG), and precuneus when processing pain-related words compared to other words. However, when attention was focused on a foreground task and words were presented in the background (distraction task), we found a decrease in activation within dorsal anterior cingulum (dACC) and a relative increase in activation within the subgenual ventral anterior cingulum (sACC) when processing pain related words compared to other words. Thus, activations to pain-related words are strongly modulated by the attention demands of the task. Most remarkably, the differences in processing pain-related words compared to non-pain-related words are specific to the pain-relevance of the words and cannot simply be explained by their valence or arousal.
We argue that the primary function of mental imagery is to allow us to generate specific predictions based upon past experience. All imagery allows us to answer 'what if' questions by making explicit and accessible the likely consequences of being in a specific situation or performing a specific action. Imagery is also characterized by its reliance on perceptual representations and activation of perceptual brain systems. We use this conception of imagery to argue that all imagery is simulation-more specifically, it is a specific type of simulation in which the mental processes that 'run' the simulation emulate those that would actually operate in the simulated scenario. This type of simulation, which we label emulation, has benefits over other types of simulations that merely mimic the content of the simulated scenario.
Imagery for pain relief, the first book of its kind, familiarizes the reader with basic scientific information about pain and mental imagery and shows why imagery is a valuable tool for pain management. Scientifically grounded and easy to read, it provides readers with a wealth of practical information, including imagery techniques that have been successfully used in the past. This is a useful text not only for physicians and clinical psychologists, but also for counselors, social workers, nurses, and graduate students in all health-related fields, including sports medicine.
Part 1 Overview of pain, assessment and treatment considerations: theories of pain and treatment approaches to pain management the cognitive conceptualization of pain the usual course and structure of cognitive therapy with chronic pain patients pain assessment. Part 2 Behavioural interventions: monitoring pain and activity levels and activity scheduling relaxation training and distraction techniques. Part 3 Cognitive interventions: identifying automatic thoughts about pain evaluating automatic thoughts about pain modifying automatic thoughts about pain and implementing problem-solving strategies identifying beliefs about pain evaluating and modifying beliefs about pain eliciting and modifying imagery. Part 4 Psychosocial stressors to address: managing their care family, friends and lifestyle issues occupational, financial and legal difficulties. Part 5 Assertiveness: assertiveness training. Part 6 Pain pharmacotherapy: pain pharmacotherapy for chronic pain patients. Part 7 Preparing for the end of therapy and beyond: preparing for termination and relapse prevention appendix - patient's report of therapy session.
A theory of emotional imagery is described which conceives the image in the brain to be a conceptual network, controlling specific somatovisceral patterns, and constituting a prototype for overt behavioral expression. Evidence for the hypothesis that differentiated efferent activity is associated with type and content of imaginal activity is considered. Recent work in cognitive psychology is described, which treats both the generation of sensory imagery and text comprehension and storage as examples of the processing of propositional information. A similar propositional analysis is applied to emotional imagery as it is employed in the therapeutic context. Experiments prompted by this view show that the conceptual structure of the image and its associated efferent outflow can be modified directly through instructions and through shaping of reports of image experience. The implications of the theory for psychopathology are considered, as well as its relevance to therapeutic behavior change.
Research into mental imagery has increased our understanding of a range of psychological problems. However, there has been little study into the spontaneous mental images experienced in response to chronic pain. This study aimed to explore the prevalence and characteristics of these pain-related mental images.
Four hundred ninety-one people with chronic pain who had attended a pain clinic were sent invites to participate and 105 people responded (21%). A mixed-methods approach (quantitative and qualitative) was used to explore the prevalence of pain-related mental imagery, differences between imagers and non-imagers, and the content of imagery in pain.
In our sample, 36% of respondents reported having mental images of their pain, with the majority describing them as clear and vivid (83%), experienced daily (80.5%), and distressing (83%). Participants who experienced mental images reported higher depression scores, higher anxiety and higher pain unpleasantness. Frequency of imagery was associated with greater pain unpleasantness. Content analysis of the pain images revealed emerging themes relating to the sensory qualities of pain, anatomical representations, pain as a form of threat or attack, pain as an object, and pain as an abstract image.
This study describes themes and characteristics of pain-related mental imagery and confirms that they are a frequent, vivid and distressing experience for many chronic pain sufferers. The results of this study suggest that pain-related mental imagery could provide an additional route for assessment and intervention. Further research should focus on assessment, measurement and intervention in clinical populations.
The imagery of itch and pain evokes emotional responses and covert motor responses (scratching to itch and withdrawal to pain). This suggests some similarity in cerebral mechanisms. However, itch is more socially contagious than pain as evidenced by the fact that scratching behaviors can be easily initiated by watching itch-inducing situations whereas withdrawal is less easily initiated by watching painful situations. Thus, we assumed that the cerebral mechanisms of itch imagery partly differ from those of pain imagery in particular with respect to motor regions. We addressed this issue in 18 healthy subjects using functional magnetic resonance imaging. The subjects were instructed to imagine itch and pain sensations in their own bodies while viewing pictures depicting stimuli associated with these sensations. Itch and pain imagery activated the anterior insular cortex (aIC) and motor-related regions such as supplementary motor area, basal ganglia, thalamus and cerebellum. Activity in these regions was not significantly different between itch and pain imagery. However, functional connectivity between motor-related regions and the aIC showed marked differences between itch and pain imagery. Connectivity with the aIC was stronger in the primary motor and premotor cortices during pain imagery and stronger in the globus pallidus during itch imagery. These findings indicate that brain regions associated with imagery of itch are the same as those involved in imagery of pain, but their functional networks differ. These differences in brain networks may explain why motor responses to itch are more socially contagious than those related to pain.
Pain is a negative emotional experience that is modulated by a variety of psychological factors through different inhibitory systems. For example, endogenous opioids and cannabinoids have been found to be involved in stress and placebo analgesia. Here we show that when the meaning of the pain experience is changed from negative to positive through verbal suggestions, the opioid and cannabinoid systems are co-activated and these, in turn, increase pain tolerance. We induced ischemic arm pain in healthy volunteers, who had to tolerate the pain as long as possible. One group was informed about the aversive nature of the task, as done in any pain study. Conversely, a second group was told that the ischemia would be beneficial to the muscles, thus emphasizing the usefulness of the pain endurance task. We found that in the second group pain tolerance was significantly higher compared to the first one, and that this effect was partially blocked by the opioid antagonist naltrexone alone and by the cannabinoid antagonist rimonabant alone. However, the combined administration of naltrexone and rimonabant antagonized the increased tolerance completely. Our results indicate that a positive approach to pain reduces the global pain experience through the co-activation of the opioid and cannabinoid systems. These findings may have a profound impact on clinical practice. For example, postoperative pain, which means healing, can be perceived as less unpleasant than cancer pain, which means death. Therefore, the behavioral and/or pharmacological manipulation of the meaning of pain can represent an effective approach to pain management.
Investigated 3 elements of stress inoculation training, a therapeutic package for helping clients control anxiety, anger, or pain. 96 undergraduate females were tested twice for ice water tolerance. In a 2–3 design, the independent variables were the presence or absence of (a) pleasant imagery, (b) a conceptualization of pain as a multistage process, and (c) planned, explicit self-instructions. A multivariate analysis of covariance using the (transformed) pretest tolerance as the covariate was performed on the tolerance rating and 2 self-ratings of pain. Imagery users (Is) controlled their pain better than nonimagery users (NIs). There was a significant interaction of Imagery and Conceptualization. NIs had longer tolerance and less self-reported pain at withdrawal when they heard pain conceptualized as a multistage process than when they heard no conceptualization. The Is did not derive additional benefit from hearing the conceptualization. Self-instruction did not affect pain control. Results suggest that pleasant imagery effectively relieves pain and may account for much of the effectiveness of stress inoculation training. (23 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This book takes as its focus the treatment of patients who are suffering pain from a variety of recurring syndromes, and whose nervous systems continue to be bombarded by noxious stimulation.
[It] explores only those approaches to pain treatment that utilize the imagination of the patient.
This volume is intended as a clinically useful guide to the practical knowledge and skill that has developed from this research tradition. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
It is widely recognized that psychological factors play a central role in the adjustment process and subsequent management of chronic pain. The role of anxiety, and specifically pain-related fear, has received particular attention. Paralleling developments in the anxiety disorders literature, psychological models of pain-related fear now highlight the importance of cognitive processes in its maintenance and treatment. However, theoretical and treatment advances in the anxiety disorders literature have not been widely applied to the pain field. In particular, certain cognitive processes, specifically safety-seeking behaviours and imagery, which appear to be involved in the maintenance of pain-related fear. This paper explores how these concepts may apply to pain-related fear and demonstrates how they may aid conceptualization and be used to guide a more cognitively orientated and efficacious treatment.
Background:
The majority of pain sufferers experience images when in pain. The most distressing of these images (the Index image) provokes intense emotional reactions, appraisal shifts, and increases in pain. The ability of pain sufferers to rescript their Index images, and the consequences of doing so, remain to be determined.
Aims:
To assess the effects upon emotions, appraisals and pain experience of rescripting Index images in pain sufferers.
Method:
The Index images of a group of 55 pain sufferers were assessed using a voluntary image induction procedure (VIE) to obtain basal levels of pain, appraisal and emotion. Participants were than randomly allocated to one of two groups: Rescripted Image repetition or Index Image repetition. The two groups were compared on their responses to their Index and Rescripted images respectively.
Results:
The participants found it easy to rescript their distressing Index images. During rescripting, they reported dramatic reductions in emotion, negative appraisals, and pain. The clinically and statistically significant decrements in pain were found independent of reductions in emotion. The pain levels during rescripting were significantly below their basal levels, with 49% reporting no pain at all while viewing a rescripted image. These changes were not a function of image repetition.
Conclusion:
Index images of pain sufferers can be easily elicited and rescripted. Rescripting leads to remarkable reductions in emotion, cognitions and pain levels that are not attributable to image repetition. The significant reductions in pain were independent of reductions in emotion. The implications of these results for CBT approaches to pain management are considered.
Aim: The aim of this paper is to summarise and critically evaluate the evidence available from controlled clinical trials regarding the use of guided imagery as a sole adjuvant therapy for cancer patients. Methods: Electronic searches for controlled clinical trials were carried out in eight databases and two clinical trial registers. Trials that featured guided imagery as a sole adjuvant therapy were included. No language restrictions were imposed. Data were extracted and validated independently by two researchers. Results: Six randomised clinical trials were included. Detailed results were available for four studies only. Poor reporting and heterogeneous populations, interventions and outcome measures across trials precluded statistical pooling of results. The methodological quality was on average low. Three studies reported significant differences in measures of anxiety, comfort or emotional response to chemotherapy for patients who received guided imagery over the control groups. Two studies showed no differences between guided imagery and other interventions in any of the outcome measures. Conclusion: Guided imagery, as a sole adjuvant cancer therapy may be psycho-supportive and increase comfort. There is no compelling evidence to suggest positive effects on physical symptoms such as nausea and vomiting. The data seem sufficiently encouraging for the use of guided imagery as an adjuvant cancer therapy to merit further research.
Cognitive and behavioral pain coping strategies were assessed by means of questionnaire in a sample of 61 chronic low back pain patients. Data analysis indicated that the questionnaire was internally reliable. While patients reported using a variety of coping strategies, certain strategies were used frequently whereas others were rarely used. Three factors: (a) Cognitive Coping and Suppression, (b) Helplessness and (c) Diverting Attention or Praying, accounted for a large proportion of variance in questionnaire responses. These 3 factors were found to be predictive of measures of behavioral and emotional adjustment to chronic pain above and beyond what may be predicted on the basis of patient history variables (length of continuous pain, disability status and number of pain surgeries) and the tendency of patients to somaticize. Each of the 3 coping factors was related to specific measures of adjustment to chronic pain.
A large number of studies have provided evidence for the efficacy of psychological and other non-pharmacological interventions in the treatment of chronic pain. While these methods are increasingly used to treat pain, remarkably few studies focused on the exploration of their neural correlates. The aim of this article was to review the findings from neuroimaging studies that evaluated the neural response to distraction-based techniques, cognitive behavioral therapy (CBT), clinical hypnosis, mental imagery, physical therapy/exercise, biofeedback, and mirror therapy. To date, the results from studies that used neuroimaging to evaluate these methods have not been conclusive and the experimental methods have been suboptimal for assessing clinical pain. Still, several different psychological and non-pharmacological treatment modalities were associated with increased pain-related activations of executive cognitive brain regions, such as the ventral- and dorsolateral prefrontal cortex. There was also evidence for decreased pain-related activations in afferent pain regions and limbic structures. If future studies will address the technical and methodological challenges of today's experiments, neuroimaging might have the potential of segregating the neural mechanisms of different treatment interventions and elucidate predictive and mediating factors for successful treatment outcomes. Evaluations of treatment-related brain changes (functional and structural) might also allow for sub-grouping of patients and help to develop individualized treatments.
This paper reviews research on the role of colour and imagery in relation to illness and examines how this might improve communication between the sufferer and those treating or caring for them. It describes a method by which colour can be related to situations such as an individual's mood and how this might be used to predict response to treatment. Furthermore, it provides evidence that documenting the imagery of an illness might give insight into the patients' fears and concerns about their condition as well as helping non-sufferers to understand what they are going through.
Distraction from pain reduces pain perception, and imaging studies have suggested that this may at least partially be mediated by activation of descending pain inhibitory systems. Here, we used the nociceptive flexor reflex (RIII reflex) to directly quantify the effects of different distraction strategies on basal spinal nociception and its temporal summation. Twenty-seven healthy subjects participated in 3 distraction tasks (mental imagery, listening to preferred music, spatial discrimination of brush stimuli) and, in a fourth task, concentrated on the painful stimulus. Results show that all 3 distraction tasks reduced pain perception, but only the brush task also reduced the RIII reflex. The concentration-on-pain task increased both pain perception and the RIII reflex. The extent of temporal summation of pain perception and the extent of temporal summation of the RIII reflex were not affected by any of the tasks. These results suggest that some, but not all, forms of pain reduction by distraction rely on descending pain inhibition. In addition, pain reduction by distraction seems to preferentially affect mechanisms of basal nociceptive transmission, not of temporal summation.
There is a dearth of information about imagery in pain sufferers.
The aim of this study was to collect data on the characteristics, prevalence, and potency of imagery associated with pain.
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.
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.
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.
Several controlled trials have demonstrated that hypnosis is an efficacious treatment for chronic pain. However, less attention has been given to the specific procedures and suggestions used in hypnotic treatments in research. The goal of this review was to address the issue of differences in the content of hypnotic suggestions, including pain management suggestions, non-pain related suggestions, and posthypnotic suggestions, in the context of published clinical trials of hypnosis for chronic pain management. This review focused on the types of suggestions used in twenty five studies comparing hypnosis to active treatments (e.g., relaxation, biofeedback), non-treatment control groups (e.g., standard care/wait-list control, supportive attention), or both in adult populations with various chronic pain conditions. Overall, these studies found hypnosis to be more effective than non-treatment control groups and similarly effective when compared to active treatments on pain-related outcomes when either pain-related suggestions or non-pain related suggestions were used. However, for studies that included both pain-specific and non-pain related suggestions, hypnosis was found to be superior to active treatments on a variety of pain-related outcomes.
The objective of this systematic review was to assess the effectiveness of guided imagery (GI) as a treatment option for musculoskeletal pain (MSP).
Six databases were searched from their inception to May 2010. All controlled clinical trials were considered, if they investigated GI in patients with any MSP in any anatomic location and if they assessed pain as an outcome measure. Trials of motor imagery were excluded. The selection of studies, data extraction, and validation were performed independently by 2 reviewers.
Nine randomized clinical trials (RCTs) met the inclusion criteria. Their methodologic quality ranged between 1 and 3 on the Jadad scale. Eight RCTs suggested that GI leads to a significant reduction of MSP. One RCT indicated no change in MSP in comparison with usual care.
It is concluded that there are too few rigorous RCTs testing the effectiveness of GI in the management of MSP. Therefore, the evidence that GI alleviates MSP is encouraging but inconclusive.
Specific aims of this pilot study were to (a) determine the effect of a guided imagery (GI) intervention over an 8-week period on pain and pain disability in a sample of persons with chronic noncancer pain (CNCP) and (b) analyze the mediating effects of neuroendocrine and neuroimmune functioning on the effectiveness of GI on outcome variables. A simple interrupted time-series design (12-week period) was used. GI was introduced at Week 4 and used daily by 25 participants for the remaining 8 weeks. Measures of pain and pain disability were obtained at the beginning of the study period and at six repeated 2-week intervals. Measures of hypothalamic-pituitary-adrenal (HPA) axis activation (plasma cortisol), immune-mediated analgesia (lymphocyte subset counts and proliferation), and immune-mediated hyperalgesia (interleukin-1β) were obtained at the beginning of the study and at Week 11. Usual pain levels were lower after the introduction of GI at Week 4 (Wilks' λ = 52.31; df = 2, 22; p = .000). Pain disability levels were lower after the introduction of GI at Week 4 (Wilks' λ = 5.98; df = 6, 18; p = .001). Correlation coefficients between change scores of dependent variables and mediating variables were not significant. GI was effective in reducing pain intensity and pain disability over an 8-week period; however, the results did not support the expected effects of decreased HPA axis activation, improved immune-mediated analgesia, and reduced immune-mediated hyperalgesia in mediating these outcomes. These findings may be related to procedural and theoretical issues and limitations related to the study design.
We developed a smartphone technology to sample people’s ongoing thoughts, feelings, and actions and found (i) that people
are thinking about what is not happening almost as often as they are thinking about what is and (ii) found that doing so typically
makes them unhappy.
A medical artist asked 109 patients if they had an image of their IBS pre- and posthypnotherapy, making precise watercolor paintings of any images described. Results were related to treatment outcome, symptoms, anxiety, depression, and absorption (hypnotizability); 49% of patients had an image, and a wide variety were recorded and painted. Imagery was significantly associated with gender (p < .05), anxiety (p < .05), noncolonic symptomatology (p < .05), and absorption (p = .001); 57.8% of responders compared with 35.5% of nonresponders to hypnotherapy had an image of their disease (p < .05) before treatment, and color images were associated with better outcomes (p = .05) than monochrome ones. All images changed in responders, often becoming more nonspecific in nature. Inquiring about IBS imagery helps to identify potential responders and nonresponders to hypnotherapy and may also provide insights into how patients think about their illness.