David Gillanders Mental Imagery in Chronic Pain by xV43uA2v

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									              University of Edinburgh
            Lothian Chronic Pain Service




        Mental Imagery in
          Chronic Pain
David Gillanders
University of Edinburgh /
NHS Lothian Chronic Pain Service
     What I’m going to tell you
A substantial proportion of chronic pain
 patients experience mental images of their
 pain

 These images are associated with higher
 anxiety, depression, catastrophising, pain
 related worry
        What we’ve done so far
 The   beginning: clinical work

      Imagery for relaxation /
 Using
 manipulation

3   studies:    Louise Potter (2007)
                 Tom Gosden (2008)
                 Jennifer Lonsdale (2010)
Study 1 – Louise Potter’s Thesis

    Postal Questionnaire study

    350 people who had attended pain clinic

    83 responses received (23%)
              Measures
Pain

Disability

Catastrophising

Anxiety

Acceptance
             Chronic Pain Imagery

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

   24% YES     (n = 19)

   We then looked at differences between those
    reporting imagery and those not on the other
    measures.
                          Results
Pain          Non significant differences between imagers
              and non imagers: t = 1.97 (df = 1, 81) p = 0.053,
d = 0.4       (though close!)


Disability    No significant difference:    t = 0.8 (df = 1, 81)
              p = 0.42, d = 0.18



Due to the effect of pain we controlled for pain in all other
analyses.

Statistics are F statistics, p values and effect sizes of
adjusted R2
                                                                 Results
                         Anxiety        Imagery group significantly more anxious
                                         than non imagery group

                     25




                     20
                                                                     F = 12.73 , (df 1, 80)
HADS Anxiety Score




                     15                                              p = 0.002

                     10
                                                                     Effect size:

                      5
                                                                     adjusted R2 = 0.23
                                                                     (23% of variance in HADS
                      0                                              attributable to imagery, even after
                                yes                         no       controlling for pain)
                                      Presence of Imagery
                                                         Results
                                                                 Depression:
                        25


                                                              Imagery group significantly
                        20                                    more depressed
HADS Depression Score




                        15                                    F = 6.12, (df = 1, 80)
                                                              p = 0.016
                        10


                                                              Effect size:
                         5
                                                              adjusted R2 = 0.12
                         0
                                                              (12% of variance in HADS D is
                                                              attributable to imagery after
                             yes                         no
                                   Presence of Imagery        controlling for pain)
                                                                          Results
                                                                                    Catastrophising:

                                         50
                                                                                    Imagery group higher
                                                                                    level of catastrophising
Score on PRSS Catastrophising Subscale




                                         40                                         thoughts
                                                                                    F = 4.45, (df 1, 80)
                                         30




                                                                                    p = 0.038
                                         20




                                                                                    Effect size:
                                                                                    Adjusted R2 = 0.21
                                         10




                                          0
                                                                                    (21% of variance in
                                              yes                         no        catastrophising attributable to
                                                    Presence of Imagery
                                                                                    imagery after pain)
                        Results
   No other significant differences between groups

•       Acceptance (general or pain specific)

•       Other cognitive variables:    resourcefulness,
                                coping thoughts,
                                helplessness

•       Pain related anxiety

    though pain related worry is close:
    F = 3.73, (df = 1, 80), p = .057, adjusted R2 = .20
              Conclusions
 Some people recognise pain images and
 can report on these

 Reporting these is associated with higher
 anxiety, depression and catastrophising,
 but not greater pain, disability or other
 psychological factors
Study 2 – Tom Gosden’s Thesis
   Find out more about the characteristics of
    mental images
           Vividness
           Frequency
           Distress
           Interference
           Controllability


   Qualitative analysis of themes in mental
    image descriptions
   Methodology
       Imagery Questionnaire
         • “We are particularly interested in finding out if you have a
           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
           things you can imagine seeing, hearing or feeling. Do you
           ever have a mental image like this of your pain?”

         • Qualitative Image description

         • Likert Type Scales
                Vividness
                Frequency
                Distress
                Interference
                Controllability
                   Results
 Participants
     New patients seen at WGH in 12 months
     Postal questionnaire (n=491)


 105   returns (22%)

 39%    report having a mental image of pain
     Results – Imagery Characteristics
    Vividness:
               20
               18
               16
               14
               12
 number of
participants   10
                8
                6
                4
                2
                0
                    no im age at   vague and   m oderately    clear and   perfectly
                         all          dim       clear and    reasonably   clear and
                                                  vivid         vivid        vivid
    Results – Imagery Characteristics
   Frequency

                 20

                 18

                 16

                 14

                 12
      number of
                  10
     participants
                  8

                  6

                  4

                  2

                  0
                       alm ost never once or tw ice once or tw ice   every day   m any tim es a
                                       a m onth        a w eek                        day
    Results – Imagery Characteristics
                    Image       Image     Image distress      Image           Image
                  vividness   frequency                    interference   controllability


    Image         1.000        .142         .338*           .313*            -.135
  vividness
    Image                     1.000          .070            .151             .034
  frequency
Image distress                              1.000          .713**            -.244
    Image                                                   1.000            -.065
 interference
    Image                                                                    1.000
controllability


* significant at the 0.05 level (two-tailed)
** significant at the 0.001 level (two-tailed)
     Results – H1 Imagery & Pain
   Imagery is associated with higher pain:
     Imagery Y/N           n        Mean McGill-SF   SD

           Y               41               22       9.4

           N               52              17.3      9.5


    t = 2.453 (df = 1,102), p = 0.016, d = 0.49
Results – H1 Imagery & 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 = 1, 91), p = 0.156, d = 0.30]
Results – H2 Imagery & Depression
   Imagery is associated with higher depression:
    Imagery Y/N          n       Mean Depression   SD
                                       Score
         Y              41              11.54      5.9

         N              52              9.19       5.16


t = 2.042 (df = 1, 91), p = 0.044, d = 0.43
   Thematic Analysis of Qualitative Descriptions
     • n=40
   Theme 1. Representations of sensory qualities
            of pain

Sub-theme: Pressure or weight


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



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


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


“I have an image of an electric short circuit running
down my legs!!” (Participant 93)
Theme 2. Anatomical Representations of
          Damage


“Bones grinding together” (Participant 32)

 “The discs in my spine crumbling or grinding together
causing my body to grind to a halt” (Participant 111)
Theme 3. A Ball of Pain


“My image looks like a large ball about the size of a tennis
ball and it looks spongy and horrible” (Participant 14)
Theme 4. Victim of Attack

“Like my body is being attacked (where problems are) by
someone with a voodoo doll or a little army inside me
making sure I am in agony!” (Participant 6)
   Study 3: Jennifer Lonsdale

 Experimental   study – within groups

 Ratings of pain intensity and emotion state
 at baseline, then after verbal processing of
 pain and image processing of pain
              Conditions
 Imagery Condition – participants
 ‘contacted’ their usual pain image in some
 detail and described it

 Verbal Condition – participants read and
 chose words from a list that best described
 their pain (based on the McGill Pain
 Questionnaire) they then constructed
 sentences to describe their pain using
 these words
      Results – Impact on emotion




Fear = no change

Anger, Sadness, Happiness & Disgust: both verbal and imaginal conditions
significantly different from baseline (t = .91 – 3.37 (df = 1, 35), p = .04 - .01)

No significant differences between verbal and imaginal conditions for any emotion
           Results – Impact on Pain




No change from baseline to verbal (t = .54, (df 1,35) p = .6, ns)

Pain significantly increased during imaginal condition (t = 2.56, (df 1,35), p = .02)

Imagery processing of pain leads to enhancement of the sensory experience of
pain significantly more than verbal processing of pain (t = 2.38, (df 1, 35), p = .02)
                 Next Steps
   Grounded Theory Qualitative Study




   Single Case Experimental Design
             Conclusions
 The fact we have replicated some of the
 findings of the earlier study is promising

 Ourunderstanding of this phenomenon is
 growing

     related images appear to be ways of
 Pain
 making sense of abnormal sensory data
              Conclusions
 Images   are a form of thought

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

 Weneed studies to establish the validity,
 and reliability of ways of measuring
 imagery
                  Conclusions
   Some images have themes of attack and / or
    future catastrophe

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

   Imagery based interventions may be a useful
    addition to current exposure and cognitive
    restructuring interventions
       Thank you for listening…

       david.gillanders@ed.ac.uk

          Acknowledgements:

    NHS Tayside Chronic Pain Service
    NHS Lothian Chronic Pain Service
    NHS Highland Chronic Pain Service

  Louise Potter            Emily Newman
  Tom Gosden              Rachel Atherton
   Paul Morris         Dee McDonnel-Boudra
Jennifer Lonsdale        Clare Phillips, UBC
  Jennifer Snell        Emily Holmes, Oxford
 Natalie Rooney        Ann Hackmann, Oxford

								
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