Mental Imagery in Chronic Pain

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					        Mental Imagery in
          Chronic Pain
David Gillanders
University of Edinburgh /
NHS Lothian Chronic Pain Service
    Outline of presentation
Clinical & Research work in Lothian
Chronic Pain Service & University of
Edinburgh

Background to this work – clinical
observations

Two studies of mental imagery in pain
    Outline of presentation
Data from those studies

Discussion of the results

A single case intervention (time
permitting!)

Future directions and next steps
       Acknowledgements
Dr. Louise Potter, Clinical Psychologist

Tom Gosden,
Trainee Clinical Psychologist
         Mental Images……
Definition

“Mental imagery refers to all those quasi-sensory or
quasi-perceptual experiences of which we are self-
consciously aware, and which exist for us in the absence
of those stimulus conditions that are known to produce
their genuine sensory or perceptual counterparts”
Richardson (1969) (p2)

Includes dreams, memories,
spontaneously and intentionally generated
images
   Background to this work
Own clinical work

Using Imagery for relaxation

Spontaneous ‘imagery like’ descriptions
Why Mental Images may be important
  Differences in imagery vividness correlate with
  differences in fMRI images in visual cortex (Cui et al.,
  2007)

  Mental Images have physiological consequences
   • Taste images increase salivation (Barber, Chauncery and
     Winer, 1964)
   • Images of bodily and emotional arousal increase galvanic
     skin response (Bauer and Craighead, 1979)
   • Images of activity increase heart rate, more “active” images
     increase HR more (Jones and Johnson, 1978; 1980)
   • Images of white blood cells attacking germs produce
     measurable immune system change (Schneider et al., 1991)
        Mental Imagery in
      Psychological Disorders
Post Traumatic Stress Disorder
                                      (Hackmann & Holmes, 2004)
Social phobia
                           (Hackmann, Clark and McManus, 2000),
Agoraphobia
                              (Day, Holmes and Hackmann, 2004),
Bulimia nervosa
                       (Somerville, Cooper and Hackmann, 2007),
Body dysmorphic disorder
                                               (Osman et al., 2004)
Depression
                            (Brewin et al., 1988; Patel et al., 2007).
Mental Imagery in Chronic Pain
  Research limited to Guided Imagery techniques
   • Imagery as most effective cognitive technique for control of
     pain (Fernandez and Turk, 1989)
   • Studies report Guided Imagery is effective for pain control in-
           •   Burn patients (Achterberg, Cornelia and Lawlis, 1988)
           •   Cancer pain (Sloman, 1995; Syrjala et al., 1995)
           •   Perioperative pain (Tusek et al., 1997)
           •   Headache (Mannix et al., 1999)
           •   Fibromyalgia (Flors, Sexton and Gotestam, 2002)
           •   Heterogeneous chronic pain clinic sample (Lewandowski
               et al., 2004)
   • Also reported positive effects of Guided Imagery on-
           • Anxiety
           • Perception of ability to cope (Illecqua 1994)
           • Change in pain beliefs (Lewandowski, Good and Drancher,
             2005)
But……
   what about naturally-occurring mental
   images…..?
  What are they like?
  Are they important?
Study 1 – Louise Potter’s Thesis

  Postal Questionnaire study

  350 people who had attended pain clinic in
  last six months

  83 responses received (23%)
                           Measures
McGill Pain Questionnaire (Short Form) (Melzack, 1987)

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

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

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

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

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

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

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

Chronic Pain Imagery
         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         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
                                                                 Results
                          Anxiety        Imagery group significantly more anxious
                                         than non imagery group

                     25




                     20



                                                                     t = 3.439, (df 81)
HADS Anxiety Score




                     15


                                                                     p = 0.001
                     10

                                                                     Effect size: d = 0.76
                      5




                      0


                                yes                         no
                                      Presence of Imagery
                                                         Results
                                                                 Depression:
                        25


                                                              Imagery group significantly
                        20                                    more depressed
HADS Depression Score




                        15                                    t = 2.276, (df 81)
                                                              p = 0.025
                        10


                                                              Effect size: d = 0.51
                         5




                         0


                             yes                         no
                                   Presence of Imagery
                                                                          Results
                                                                                      Catastrophising:
                                         50

                                                                                    Imagery group higher
                                                                                    level of catastrophising
Score on PRSS Catastrophising Subscale




                                         40


                                                                                    thoughts
                                         30


                                                                                    t = 2.97, (df 81)
                                         20                                         p = 0.008
                                                                                    Effect size: d = 0.67
                                         10




                                          0


                                              yes                         no
                                                    Presence of Imagery
                  Results
No other significant differences between groups

Acceptance (general or pain specific)

Other cognitive variables: resourcefulness,
                           coping thoughts,
                           helplessness

Pain related anxiety
           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
             Limitations

Poor return rate
Smallish sample size
Inadequate measurement of imagery
Incomplete theoretical conceptualisation of
imagery
           Next steps…
Can we get more detail?
Can we measure this more reliably?
Can we figure out what this imagery is
about?
Is this an artefact of asking about it?
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

   • Visual Analogue Scales
         Vividness
         Frequency
         Distress
         Interference
         Controllability
 Chronic Pain Imagery Measure
How vivid (how strong and clear) is this
 image? (tick one)

perfectly clear and as vivid as normal vision
clear and reasonably vivid
moderately clear and vivid
vague and dim
no image at all, you only “know” that you are
  thinking of an object
 Chronic Pain Imagery Measure
How distressing or pleasant is this image for you?
(please mark the line at the point which best fits your experience)

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

  very distressing                neither distressing nor pleasant             very pleasant



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

        0      10     20     30       40     50     60      70       80   90      100

no control                                  moderate                       complete
at all                                      control                         control
        Other measures
McGill Pain Questionnaire- Short Form
(Melzack, 1985)

Spontaneous use of Imagery Scale
(Reisberg, Pearson, & Kosslyn, 2003)

DAPOS (Pincus et al., 2004)
 • Depression
 • Anxiety
 • Positive Outlook
             Other measures
   Spontaneous Use of Imagery Scale (SUIS)

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

I prefer to read novels that lead me easily to visualize
where the characters are and what they are doing
instead of novels that are difficult to visualize.
               Results
Participants
  New patients seen at WGH (1.4.07-1.4.08)
  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

Distress: Mean rating = -26 or ‘moderately unpleasant’
          (No ratings of pleasant)

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

Controllability:   Mean rating = 40 (SD 32)    ‘moderately
                                              controllable’
    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 & 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 – H2 Imagery & 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 – H3 Imagery & Use of
    Imagery in Everyday Life
Imagery 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 Descriptions
 • n=40
                     Crushing

“Being enclosed in a metal band”
“Of a vice crushing my foot”
“Low back pain/nerve pain- sometimes as if I am
under a giant metal press crushing my chest and
throat, head”
“As if I’m lying in the middle of a road and a road
roller keeps driving over me”
“Sometimes feels like a vice below my knee”
“Someone squeezing my ankle and foot in a vice or
with their hands”
                Victim of Attack

“Like someone pulling every part of my leg from the
inside out”
“I feel as though someone is hitting me at the base of
my back, causing it to feel weak”
“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!”
“Someone stabbing the soles of my feet”
“Having my back teeth pulled out WITHOUT
anaesthetic”
“It is like all the inflamed area of my lower back has
been pinpointed for attack so everything just moves
to this area, making the pain worse. I think there is
all this redness, inflammation, muscle damage around
the herniated disk”
“Very sharp, jagged teeth searing into my neck like
the jaws of a shark”
“It’s like a red hot poker inserted anally”
“Fire going up and down my left side as if someone has
a lighted torch trying to set my left side on fire”
“Yes, a big pain worm or bug eating at the site of pain.
Only relief is to keep squashing it with as much
pressure as possible”
“As if I’m lying in the middle of a road and a road
roller keeps driving over me”
“Someone squeezing my ankle and foot in a vice or
with their hands”
           Ball of Pain/Externalising

“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 my breasts”
“My image looks like a large ball about the size of a
tennis ball and it looks spongy and horrible”
“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 throbs”
                      Blades

“Like a knife or broken glass being stabbed in my leg”
“Someone stabbing the soles of my feet”
“Very sharp, jagged teeth searing into my neck like
the jaws of a shark”
“Walking on very rough ground/broken glass”
“A knife being twisted”
“The sciatica/femoral nerve pain- like a thick blade
being pushed under the skin”
                   Burning Heat

“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 my breasts”
“A burning down the nerve in my leg”
“I can feel sometimes as though an electric heat is
being applied to my right leg”
“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 throbs”
“It’s like a red hot poker inserted anally”
“Fire going up and down my left side as if someone has
a lighted torch trying to set my left side on fire”
                    Electricity

“I can feel sometimes as though an electric heat is
being applied to my right leg”
“Electricity running along wires, electric shocks”
“As if strong electric volt shooting through cheek!”
  Anatomical Representation of Damage

“It is like all the inflamed area of my lower back has
been pinpointed for attack so everything just moves
to this area, making the pain worse. I think there is
all this redness, inflammation, muscle damage around
the herniated disk”
“I could imagine the damage that was done trying to
clear my water pipe. Nerve ends?”
“A burning down the nerve in my leg”
“Bones grinding together”
        Idiosyncratic but Interesting

“I see my body as two triangles resting on each other
with the sharp ends meeting at the small of my back.
The small area of meeting produces the bad pain”
“Like a piano string being twanged”
“Like a football hitting left side of face at 100 miles!”
“Where the pain occurs, will see that part of body
the different sensations present. A hazy outline of
what am not sure”
“R shoulder is a passenger, or a burden. R hand has a
glove on it”
“Small gastric chemicals swimming around my leg’s
with a rod in each leg buzzing”
      Just a verbal description?
“It’s a shooting pain plus pins and
needles”
“A persistent gnawing pain that never
goes away”
“That unbearable pain in the forehead
that comes when eating icecream too
quickly, but the pain does not go away”
                           Unclear
“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 depression
tablets from the doctors. I feel a bit calm with I hope to god
the doctors can give me something better than that and take
the pain away”
“I can visualise the pain that I know IS coming, so I hate later
on in the day as I know what’s coming”
“My image is like seeing myself going up like a balloon. I have lost
2 stone in 1 year have started putting on weight”
“I see faces in the sky”
“Sometimes I just want to crash the car or just take all my
tablets”
“The pain sometimes makes me wonder if I will end up a cripple
or housebound. I also wonder if I will get dementia as my illness
causes me to have extremely bad memory and I haven’t slept for
years (through a whole night)”
               Study 3
Follow up interviews with those reporting
mental images to explore in further depth

Interview guided by a semi-structured
interview based on social phobia studies

Asked participants to get in touch with the
image and rate any changes in pain,
emotion and physiological sensations
            Participants
14 people invited, but two could not bring
the image to mind

N = 12       3 male    9 female

No differences between interviewees and
other mental imagers on other
questionnaires
          Hypotheses & Results
Mental Images will be stable over time

alw ays exactly the
       sam e

very sim ilar every
       tim e

   changes a little

        changes
      significantly

        changes
      dram atically

                      0   1   2          3         4    5   6
                              num ber of participants
               Hypotheses & Results
  Pain Intensity will increase when people contact their
  pain image
  (n.s. [χ2=0 (df=1), p=1]

               5


               4


               3
 num ber of
participants
               2


               1


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                    Hypotheses & Results
       Participants will subjectively report an increase in
       physiological arousal when describing their image
   [χ2=5.333 (df=1), p=.021, d=1.79]
               10

                                                                                       Muscular Tension
               8
                                                                                       Sw eatiness
                                                                                       Heart Rate
               6
                                                                                       Breathing rate
 num ber of
participants
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               Hypotheses & Results
   Participants will experience a shift toward negative
   emotionality whilst describing their image
[χ2=8.333 (df=1), p=.004, d=3.01]
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participants
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               Study 4
2 single case experimental designs

Use guided visualisation to manipulate
images

Examine the impact on self report ratings
             Measures
Visual analogue ratings of

Pain
Distress
Control of Pain
                   Participant
•50 year old man with mixed connective tissue disease


•Multiple painful condition (autoimmune disorder affecting
collagen and cartilage as well as lung tissue)


•Developed high level of imagery skill
                 Intervention
Interventions:

      Distracting Imagery (personal): Skiing


      Focussing Imagery: (generic): Pain as object


      Idiosyncratic Imagery:   White Room
                       Design
A – Baseline:      General Conversation / Catch up at
                   beginning of session Ratings at 0, 5
                   and 10 minutes


B – Intervention 1: 5 minutes of breathing relaxation
                    1 rating



C – Intervention 2: 10 minutes of Imagery Intervention
                    1 rating
                          Results
 Skiing visualisation


10
 9
 8
 7
 6                                                      Pain
 5                                                      Control
 4                                                      Distress
 3
 2
 1
 0
     Base 1      Base 2   Base 3   Breath 1   SKI Vis
                           Results
Pain as Object visualisation

10
 9
 8
 7
 6                                                     Pain
 5                                                     Control
 4                                                     Distress
 3
 2
 1
 0
     Base 1     Base 2     Base 3   Breath 1 OBJ Vis
                               Results
     White Room visualisation (distraction?)

10
 9
 8
 7
 6                                                           Pain
 5                                                           Control
 4                                                           Distress
 3
 2
 1
 0
        Base 1     Base 2     Base 3     Breath 1   WR Vis
                          Results
     Extended Breathing


10
 9
 8
 7
 6                                                 Pain
 5                                                 Control
 4                                                 Distress
 3
 2
 1
 0
       Base 1 Base 2 Base 3 Breath Breath WR Vis
                              1      2
                                    Results
     How long does it last?


10
 9
 8
 7
 6                                                                    Pain
 5                                                                    Control
 4                                                                    Distress
 3
 2
 1
 0
                            r

                                     s

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                              5
B

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                                    10

                                           45

                                                  5

                                                            2
                                                1.
     Does it work without training?
•Atypical Facial Pain
Beach Visualisation (Distraction) Before, After
10
 9
 8
 7
 6
                                                  Pain
 5
                                                  Distress
 4
 3
 2
 1
 0
            Base 1                 After
               Conclusions
Pain related mental imagery is present in a
substantial number of pain patients

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

It is not a function of having more pain

It is unlikely to be simply an artefact of this
enquiry
            Limitations
Small sample size

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

The interviews give us a bit more
confidence but again small numbers
            Limitations
Still need to develop a good measure of
imagery

These studies bring us a few steps closer
to developing imagery measures
            Conclusions
The fact we have replicated some of the
findings of the earlier study is promising

Our understanding of this phenomenon is
growing

Pain related images appear to be ways of
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

We need 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
            Next steps
Continue working on imagery
conceptualisation

Construct good measures

Examine relationships between imagery
measures and other constructs
              Next steps
Continue to examine imagery intervention in
single case experimental research

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

Use all of that to refine our conceptual
understanding of imagery and its role in problem
development and maintenance.
          Thank you for listening…


         david.gillanders@ed.ac.uk


             Acknowledgements:
                Louise Potter
                Tom Gosden
Paul Morris, Lecturer, University of Edinburgh