Mental Imagery in Mental Imagery in Chronic PainChronic Pain

David GillandersDavid Gillanders

University of Edinburgh / University of Edinburgh /

NHS Lothian Chronic Pain ServiceNHS Lothian Chronic Pain Service

University of EdinburghUniversity of Edinburgh

Lothian Chronic Pain ServiceLothian Chronic Pain Service

AcknowledgementsAcknowledgements

Dr. Louise Potter, Clinical Psychologist, Dr. Louise Potter, Clinical Psychologist, NHS LanarkshireNHS Lanarkshire

Dr. Tom Gosden, Clinical Psychologist, Dr. Tom Gosden, Clinical Psychologist, NHS Fife NHS Fife

Dr. Paul Morris, Health Psychologist, Dr. Paul Morris, Health Psychologist, University of EdinburghUniversity of Edinburgh

Background to this workBackground to this work

Own clinical workOwn clinical work

Using Imagery for relaxationUsing Imagery for relaxation

Spontaneous ‘imagery like’ descriptionsSpontaneous ‘imagery like’ descriptions

Overt reporting of imagesOvert reporting of images

Mental Imagery in Mental Imagery in Psychological DisordersPsychological Disorders

Post Traumatic Stress Disorder Post Traumatic Stress Disorder (Hackmann & Holmes, 2004)(Hackmann & Holmes, 2004)

Social phobia Social phobia (Hackmann, Clark and McManus, 2000),(Hackmann, Clark and McManus, 2000),

Agoraphobia Agoraphobia (Day, Holmes and Hackmann, 2004),(Day, Holmes and Hackmann, 2004),

Bulimia nervosa Bulimia nervosa (Somerville, Cooper and Hackmann, 2007),(Somerville, Cooper and Hackmann, 2007),

Body dysmorphic disorder Body dysmorphic disorder (Osman et al., 2004)(Osman et al., 2004)

Depression Depression (Brewin et al., 1988; Patel et al., 2007).(Brewin et al., 1988; Patel et al., 2007).

Do pain patient’s report mental imagery Do pain patient’s report mental imagery related to their pain…..?related to their pain…..?

What are they like?What are they like? Are they important?Are they important?

Postal Questionnaire studyPostal Questionnaire study

350 people who had attended pain clinic 350 people who had attended pain clinic

83 responses received (23%)83 responses received (23%)

Study 1 – Louise Potter’s ThesisStudy 1 – Louise Potter’s Thesis

MeasuresMeasures McGill Pain Questionnaire (Short Form)McGill Pain Questionnaire (Short Form) (Melzack, 1987) (Melzack, 1987)

Hospital Anxiety and Depression Scale Hospital Anxiety and Depression Scale (HADS, Zigmond and Snaith, (HADS, Zigmond and Snaith, 1983)1983)

Roland and Morris Sickness Impact ProfileRoland and Morris Sickness Impact Profile (R+M SIP, Roland and (R+M SIP, Roland and Morris, 1983)Morris, 1983)

Chronic Pain Acceptance QuestionnaireChronic Pain Acceptance Questionnaire (CPAQ, McCracken et al, 2004) (CPAQ, McCracken et al, 2004)

Acceptance and Action Questionnaire-Revised Acceptance and Action Questionnaire-Revised (AAQ-R, Hayes et al, (AAQ-R, Hayes et al, 2004)2004)

Pain Related Control ScalePain Related Control Scale (PRCS, Flor et al, 1993) (PRCS, Flor et al, 1993)

Pain Related Self Statement ScalePain Related Self Statement Scale (PRSS, Flor et al, 1993) (PRSS, Flor et al, 1993)

Pain Anxiety Stress ScalePain Anxiety Stress Scale (PASS20, Roelofs et.al., 2004) (PASS20, Roelofs et.al., 2004)

Chronic Pain ImageryChronic Pain Imagery

““Some people report having mental images Some people report having mental images and/or pictures of their pain, do you have and/or pictures of their pain, do you have these?”these?”

24% YES24% YES ( (n n = 19) = 19)

We then looked at differences between those We then looked at differences between those reporting imagery and those not on the other reporting imagery and those not on the other measures.measures.

ResultsResults

Pain No significant differences between imagers and non imagers: t=0.92 (df = 81) p >0.05, d = 0.2

Disability No significant difference: t=0.4 (df = 81)

p >0.05, d = 0.09

ResultsResults AnxietyAnxiety Imagery group significantly more anxious Imagery group significantly more anxious

than non imagery groupthan non imagery group

yes no

Presence of Imagery

0

5

10

15

20

25

HA

DS

An

xie

ty S

co

re t = 3.439, (df 81)

p = 0.001

Effect size: d = 0.76

ResultsResults Depression:Depression:

Imagery group significantlyImagery group significantlymore depressedmore depressed

yes no

Presence of Imagery

0

5

10

15

20

25

HA

DS

Dep

ress

ion

Sco

re

t = 2.276, (df 81)

p = 0.025

Effect size: d = 0.51

ResultsResults

Catastrophising:Catastrophising:

Imagery group higher Imagery group higher level of catastrophising level of catastrophising

thoughtsthoughts

yes no

Presence of Imagery

0

10

20

30

40

50

Sco

re o

n P

RS

S C

atas

tro

ph

isin

g S

ub

scal

e

t = 2.97, (df 81)p = 0.008 Effect size: d = 0.67

ResultsResults No other significant differences between groupsNo other significant differences between groups

Acceptance (general or pain specific)Acceptance (general or pain specific)

Other cognitive variables: Other cognitive variables: resourcefulness, resourcefulness, coping thoughts, coping thoughts,

helplessnesshelplessness

Pain related anxietyPain related anxiety

ConclusionsConclusions

Some people recognise pain images and Some people recognise pain images and can report on thesecan report on these

Reporting these is associated with higher Reporting these is associated with higher anxiety, depression and catastrophising, anxiety, depression and catastrophising, but not greater pain, disability or other but not greater pain, disability or other psychological factorspsychological factors

LimitationsLimitations

Poor return rate Poor return rate

Smallish sample sizeSmallish sample size

Inadequate measurement of imageryInadequate measurement of imagery

Incomplete theoretical conceptualisation of Incomplete theoretical conceptualisation of

imagery imagery

Next steps…Next steps…

Can we get more detail?Can we get more detail? Can we measure this more reliably?Can we measure this more reliably? Can we figure out what this imagery is Can we figure out what this imagery is

about?about? Is this an artefact of asking about it?Is this an artefact of asking about it?

Study 2 – Tom Gosden’s ThesisStudy 2 – Tom Gosden’s Thesis

Find out more about the characteristics of Find out more about the characteristics of mental imagesmental images

VividnessVividness FrequencyFrequency DistressDistress InterferenceInterference ControllabilityControllability

Qualitative analysis of themes in mental Qualitative analysis of themes in mental image descriptionsimage descriptions

MethodologyMethodology Imagery QuestionnaireImagery Questionnaire

• ““We are particularly interested in finding out if you have a We are particularly interested in finding out if you have a picture or a mental image of what your pain is like. A mental picture or a mental image of what your pain is like. A mental image is like having a picture in your head which may include image is like having a picture in your head which may include things you can imagine seeing, hearing or feeling. Do you things you can imagine seeing, hearing or feeling. Do you ever have a mental image like this of your pain?”ever have a mental image like this of your pain?”

• Qualitative Image descriptionQualitative Image description

• Visual Analogue ScalesVisual Analogue Scales VividnessVividness FrequencyFrequency DistressDistress InterferenceInterference ControllabilityControllability

Chronic Pain Imagery MeasureChronic Pain Imagery Measure

How vivid (how strong and clear) is this image? How vivid (how strong and clear) is this image? (tick one)(tick one)

perfectly clear and as vivid as normal visionperfectly clear and as vivid as normal vision clear and reasonably vividclear and reasonably vivid moderately clear and vividmoderately clear and vivid vague and dimvague and dim no image at all, you only “know” that you are no image at all, you only “know” that you are

thinking of an objectthinking of an object

Chronic Pain Imagery MeasureChronic Pain Imagery Measure

How distressing or pleasant is this image for you? How distressing or pleasant is this image for you? (please mark the line at the point which best fits your experience)(please mark the line at the point which best fits your experience)

-50 -40 -30 -20 -10 0 10 20 30 40 50-50 -40 -30 -20 -10 0 10 20 30 40 50

very distressing very distressing neither distressing nor pleasant neither distressing nor pleasant very pleasant very pleasant

How much are you able to control what happens in this image?How much are you able to control what happens in this image?(please mark the line at the point which best fits your experience)(please mark the line at the point which best fits your experience)

0 10 20 30 40 50 60 70 80 90 1000 10 20 30 40 50 60 70 80 90 100

no control no control moderate moderate complete completeat all at all control control control control

Other measuresOther measures

McGill Pain Questionnaire- Short Form McGill Pain Questionnaire- Short Form

(Melzack, 1985)(Melzack, 1985)

Spontaneous use of Imagery ScaleSpontaneous use of Imagery Scale

((Reisberg, Pearson, & Kosslyn, 2003)Reisberg, Pearson, & Kosslyn, 2003)

DAPOS (Pincus et al., 2004)DAPOS (Pincus et al., 2004)• DepressionDepression• AnxietyAnxiety• Positive OutlookPositive Outlook

Other measuresOther measures

Spontaneous Use of Imagery Scale (SUIS)Spontaneous Use of Imagery Scale (SUIS)

When I think about visiting a relative, I almost always When I think about visiting a relative, I almost always have a clear mental picture of him or herhave a clear mental picture of him or her

I prefer to read novels that lead me easily to visualize I prefer to read novels that lead me easily to visualize where the characters are and what they are doing where the characters are and what they are doing instead of novels that are difficult to visualize.instead of novels that are difficult to visualize.

ResultsResults

ParticipantsParticipants New patients seen at WGH (1.4.07-1.4.08)New patients seen at WGH (1.4.07-1.4.08) Postal questionnaire (n=491)Postal questionnaire (n=491)

105 returns (22%)105 returns (22%)

39% report having a mental image of pain39% report having a mental image of pain

Results – Imagery CharacteristicsResults – Imagery Characteristics

Vividness:Vividness:

0

2

4

6

8

10

12

14

16

18

20

number of participants

no image atall

vague anddim

moderatelyclear and

vivid

clear andreasonably

vivid

perfectlyclear and

vivid

Results – Imagery CharacteristicsResults – Imagery Characteristics FrequencyFrequency

0

2

4

6

8

10

12

14

16

18

20

number of participants

almost never once or tw icea month

once or tw icea week

every day many times aday

Results – Imagery CharacteristicsResults – Imagery Characteristics

Distress:Distress: Mean rating = -26 or Mean rating = -26 or ‘moderately ‘moderately unpleasant’unpleasant’

(No ratings of pleasant)(No ratings of pleasant)

Interference:Interference: Mean rating = 53 (SD 33)Mean rating = 53 (SD 33) ‘moderately ‘moderately interfering’interfering’

Controllability:Controllability: Mean rating = 40 (SD 32) Mean rating = 40 (SD 32) ‘moderately ‘moderately controllable’controllable’

Results – Imagery CharacteristicsResults – Imagery CharacteristicsImage

vividnessImage

frequencyImage distress Image

interferenceImage

controllability

Image vividness

1.000 .142 .338* .313* -.135

Image frequency

1.000 .070 .151 .034

Image distress 1.000 .713** -.244

Image interference

1.000 -.065

Image controllability

1.000

* significant at the 0.05 level (two-tailed)** significant at the 0.001 level (two-tailed)

Results – HResults – H11 Imagery & Anxiety Imagery & Anxiety

Imagery is not associated with higher anxiety:Imagery is not associated with higher anxiety:

Imagery Y/N n Mean Anxiety Score SD

Y 41 6.83 3.79

N 52 5.75 3.46

[t=1.432 (df=91), p=0.156, d=0.30]

Results – HResults – H22 Imagery & Depression Imagery & Depression

Imagery is associated with higher depression:Imagery is associated with higher depression:

Imagery Y/N n Mean Depression Score SD

Y 41 11.54 5.9

N 52 9.19 5.16

[t=2.042 (df=91), p=0.044, d=0.43]

Results – HResults – H33 Imagery & Use of Imagery & Use of

Imagery in Everyday LifeImagery in Everyday Life Imagery is associated with higher spontaneous imageryImagery is associated with higher spontaneous imagery

Imagery Y/N n Mean SUI Score SD

Y 41 3.25 0.8

N 52 2.91 0.83

[t=2.024 (df=97), p=0.046, d=0.41]

Thematic Analysis of Qualitative DescriptionsThematic Analysis of Qualitative Descriptions• n=40n=40

Theme 1. Representations of sensory qualities Theme 1. Representations of sensory qualities of painof pain

Sub-theme: Pressure or weightSub-theme: Pressure or weight

“…“…Sometimes as if I am under a giant metal press Sometimes as if I am under a giant metal press crushing my chest and throat, head” (Participant 28)crushing my chest and throat, head” (Participant 28)

““As if I’m lying in the middle of a road and a road roller As if I’m lying in the middle of a road and a road roller keeps driving over me” (Participant 33)keeps driving over me” (Participant 33)

““I have a mental image of a large hand inside the base of I have a mental image of a large hand inside the base of my spine squeezing as hard as it can, relentlessly…” my spine squeezing as hard as it can, relentlessly…” (Participant 97)(Participant 97)

Sub-theme:. SharpnessSub-theme:. Sharpness

““Like a knife or broken glass being stabbed in my leg” Like a knife or broken glass being stabbed in my leg” (Participant 23)(Participant 23)

“ “Very sharp, jagged teeth searing into my neck like the Very sharp, jagged teeth searing into my neck like the jaws of a shark” (Participant 25)jaws of a shark” (Participant 25)

“ “If the pain is very sharp I imagine it as knitting needles If the pain is very sharp I imagine it as knitting needles being launched down various routes both in my back and being launched down various routes both in my back and legs” (Participant 104)legs” (Participant 104)

Sub-theme: Burning HeatSub-theme: Burning Heat

““like a red hot poker” (Participant 26)like a red hot poker” (Participant 26)

““Fire going up and down my left side as if someone has Fire going up and down my left side as if someone has a lighted torch trying to set my left side on fire” a lighted torch trying to set my left side on fire” (Participant 27)(Participant 27)

Sub-theme: ElectricitySub-theme: Electricity

“ “Electricity running along wires, electric shocks…” Electricity running along wires, electric shocks…” (Participant 16)(Participant 16)

“… “…The pain down my leg is like a bolt of lightning” The pain down my leg is like a bolt of lightning” (Participant 97)(Participant 97)

““I have an image of an electric short circuit running I have an image of an electric short circuit running down my legs!!” (Participant 93)down my legs!!” (Participant 93)

Sub-theme: VibrationSub-theme: Vibration

““Like a piano string being twanged” (Participant 13)Like a piano string being twanged” (Participant 13)

Theme 2. Anatomical Representations of Theme 2. Anatomical Representations of DamageDamage

“…“…I think there is all this redness, inflammation, muscle I think there is all this redness, inflammation, muscle damage around the herniated disk” (Participant 22)damage around the herniated disk” (Participant 22)

““Bones grinding together” (Participant 32)Bones grinding together” (Participant 32)

“ “The discs in my spine crumbling or grinding together The discs in my spine crumbling or grinding together causing my body to grind to a halt” (Participant 111)causing my body to grind to a halt” (Participant 111)

Theme 3. A Ball of PainTheme 3. A Ball of Pain

““I often think that the pain is like a burning coal just smaller I often think that the pain is like a burning coal just smaller than a golf ball but bigger than a marble that rolls around than a golf ball but bigger than a marble that rolls around my breasts” (Participant 1)my breasts” (Participant 1)

““My image looks like a large ball about the size of a tennis My image looks like a large ball about the size of a tennis ball and it looks spongy and horrible” (Participant 14)ball and it looks spongy and horrible” (Participant 14)

““It’s like a ball of pain- almost a knot of my kidney/right-hand It’s like a ball of pain- almost a knot of my kidney/right-hand side area and it gets hot and sore and moves about, and side area and it gets hot and sore and moves about, and throbs” (Participant 18)throbs” (Participant 18)

Theme 4. Victim of AttackTheme 4. Victim of Attack

““Like my body is being attacked (where problems are) by Like my body is being attacked (where problems are) by someone with a voodoo doll or a little army inside me someone with a voodoo doll or a little army inside me making sure I am in agony!” (Participant 6)making sure I am in agony!” (Participant 6)

““It is like all the inflamed area of my lower back has been It is like all the inflamed area of my lower back has been pinpointed for attack so everything just moves to this area, pinpointed for attack so everything just moves to this area, making the pain worse…” (Participant 22)making the pain worse…” (Participant 22)

““Yes, a big pain worm or bug eating at the site of pain. Yes, a big pain worm or bug eating at the site of pain. Only relief is to keep squashing it with as much pressure Only relief is to keep squashing it with as much pressure as possible” (Participant 30)as possible” (Participant 30)

Theme 5. Expressions of distress Theme 5. Expressions of distress (not images?)(not images?)

““When the pain comes very stronger I scream and cry, I When the pain comes very stronger I scream and cry, I can’t take it and usually I get stress that’s why I get can’t take it and usually I get stress that’s why I get depression tablets from the doctors. I feel a bit calm with I depression tablets from the doctors. I feel a bit calm with I hope to god the doctors can give me something better hope to god the doctors can give me something better than that and take the pain away” (Participant 4)than that and take the pain away” (Participant 4)

““I can visualise the pain that I know IS coming, so I hate I can visualise the pain that I know IS coming, so I hate later on in the day as I know what’s coming” (Participant later on in the day as I know what’s coming” (Participant 9)9)

“ “Sometimes I just want to crash the car or just take all Sometimes I just want to crash the car or just take all my tablets” (Participant 34)my tablets” (Participant 34)

Theme 6. Verbal descriptions of sensory qualities Theme 6. Verbal descriptions of sensory qualities of pain of pain (not images?)(not images?)

““It’s a shooting pain plus pins and needles” (Participant 7)It’s a shooting pain plus pins and needles” (Participant 7)

““A persistent gnawing pain that never goes away” A persistent gnawing pain that never goes away” (Participant 29)(Participant 29)

““That unbearable pain in the forehead that comes when That unbearable pain in the forehead that comes when eating ice-cream too quickly, but the pain does not go eating ice-cream too quickly, but the pain does not go away” (Participant 12)away” (Participant 12)

Theme 7. UnclearTheme 7. Unclear

““My image is like seeing myself going up like a balloon. My image is like seeing myself going up like a balloon. I have lost 2 stone in 1 year and have started putting I have lost 2 stone in 1 year and have started putting on weight…” (Participant 10)on weight…” (Participant 10)

““I see faces in the sky” (Participant 17)I see faces in the sky” (Participant 17)

LimitationsLimitations

Small sample sizeSmall sample size

Its difficult to measure: some of the Its difficult to measure: some of the descriptions appear more imagery like descriptions appear more imagery like than othersthan others

Not full qualitative analysis (e.g. grounded Not full qualitative analysis (e.g. grounded theory)theory)

LimitationsLimitations

Measurement: DAPOS – possibly not a Measurement: DAPOS – possibly not a good measure of anxiety (3 items)good measure of anxiety (3 items)

ConclusionsConclusions

Pain related mental imagery is present in a Pain related mental imagery is present in a substantial number of pain patientssubstantial number of pain patients

It is linked to catastrophising responses to pain It is linked to catastrophising responses to pain and also anxiety and depressionand also anxiety and depression

It is not a function of having more painIt is not a function of having more pain

It is unlikely to be simply an artefact of this It is unlikely to be simply an artefact of this enquiryenquiry

LimitationsLimitations

Still need to develop a good measure of Still need to develop a good measure of imageryimagery

These studies bring us a few steps closer These studies bring us a few steps closer to developing imagery measuresto developing imagery measures

ConclusionsConclusions

The fact we have replicated some of the The fact we have replicated some of the findings of the earlier study is promising findings of the earlier study is promising

Our understanding of this phenomenon is Our understanding of this phenomenon is growinggrowing

Pain related images appear to be ways of Pain related images appear to be ways of making sense of abnormal sensory datamaking sense of abnormal sensory data

ConclusionsConclusions

Images are a form of thoughtImages are a form of thought

We have a long history of measuring We have a long history of measuring verbal thoughts and relatively little verbal thoughts and relatively little regarding non-verbal thoughtsregarding non-verbal thoughts

We need studies to establish the validity, We need studies to establish the validity, and reliability of ways of measuring and reliability of ways of measuring imageryimagery

ConclusionsConclusions

Some images have themes of attack and / or Some images have themes of attack and / or future catastrophefuture catastrophe

It is likely (though not yet established) that these It is likely (though not yet established) that these kinds of thoughts will play a role in cueing kinds of thoughts will play a role in cueing avoidance behavioursavoidance behaviours

Imagery based interventions may be a useful Imagery based interventions may be a useful addition to current exposure and cognitive addition to current exposure and cognitive restructuring interventions restructuring interventions

Next stepsNext steps

Continue working on imagery Continue working on imagery conceptualisationconceptualisation

Construct good measuresConstruct good measures

Examine relationships between imagery Examine relationships between imagery measures and other constructsmeasures and other constructs

Next stepsNext steps

Continue to examine imagery intervention in Continue to examine imagery intervention in single case experimental researchsingle case experimental research

Refine our understanding of for whom does Refine our understanding of for whom does imagery intervention work best and what kinds of imagery intervention work best and what kinds of problems associated with painproblems associated with pain

Use all of that to refine our conceptual Use all of that to refine our conceptual understanding of imagery and its role in problem understanding of imagery and its role in problem development and maintenance.development and maintenance.

Thank you for listening…Thank you for listening…

david.gillanders@ed.ac.ukdavid.gillanders@ed.ac.uk

Acknowledgements:Acknowledgements:Louise PotterLouise PotterTom GosdenTom Gosden

Paul Morris, Lecturer, University of EdinburghPaul Morris, Lecturer, University of Edinburgh