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Mental Imagery in Chronic Pain

University of Edinburgh Lothian Chronic Pain Service. Mental Imagery in Chronic Pain. David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service. Acknowledgements. Dr. Louise Potter, Clinical Psychologist, NHS Lanarkshire Dr. Tom Gosden, Clinical Psychologist, NHS Fife

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Mental Imagery in Chronic Pain

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  1. University of Edinburgh Lothian Chronic Pain Service Mental Imagery in Chronic Pain David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service

  2. Acknowledgements • Dr. Louise Potter, Clinical Psychologist, NHS Lanarkshire • Dr. Tom Gosden, Clinical Psychologist, NHS Fife • Dr. Paul Morris, Health Psychologist, University of Edinburgh

  3. Background to this work • Own clinical work • Using Imagery for relaxation • Spontaneous ‘imagery like’ descriptions • Overt reporting of images

  4. 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).

  5. Do pain patient’s report mental imagery related to their pain…..? • What are they like? • Are they important?

  6. Study 1 – Louise Potter’s Thesis • Postal Questionnaire study • 350 people who had attended pain clinic • 83 responses received (23%)

  7. 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 (PASS20, Roelofs et.al., 2004)

  8. 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.

  9. 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

  10. Results • Anxiety Imagery group significantly more anxious than non imagery group t = 3.439, (df 81) p = 0.001 Effect size: d = 0.76

  11. Results • Depression: Imagery group significantly more depressed t = 2.276, (df 81) p = 0.025 Effect size: d = 0.51

  12. Results • Catastrophising: Imagery group higher level of catastrophising thoughts t = 2.97, (df 81) p = 0.008 Effect size: d = 0.67

  13. Results • No other significant differences between groups Acceptance (general or pain specific) Other cognitive variables: resourcefulness, coping thoughts, helplessness Pain related anxiety

  14. 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

  15. Limitations • Poor return rate • Smallish sample size • Inadequate measurement of imagery • Incomplete theoretical conceptualisation of imagery

  16. 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?

  17. Find out more about the characteristics of mental images Vividness Frequency Distress Interference Controllability Qualitative analysis of themes in mental image descriptions Study 2 – Tom Gosden’s Thesis

  18. 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

  19. 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 

  20. 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

  21. 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

  22. 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.

  23. 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

  24. Results – Imagery Characteristics • Vividness:

  25. Results – Imagery Characteristics • Frequency

  26. 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’

  27. Results – Imagery Characteristics * significant at the 0.05 level (two-tailed) ** significant at the 0.001 level (two-tailed)

  28. Results – H1 Imagery & Anxiety • Imagery is not associated with higher anxiety: [t=1.432 (df=91), p=0.156, d=0.30]

  29. Results – H2 Imagery & Depression • Imagery is associated with higher depression: [t=2.042 (df=91), p=0.044, d=0.43]

  30. Results – H3 Imagery & Use of Imagery in Everyday Life • Imagery is associated with higher spontaneous imagery [t=2.024 (df=97), p=0.046, d=0.41]

  31. Thematic Analysis of Qualitative Descriptions • n=40

  32. Theme 1. Representations of sensory qualities of pain Sub-theme: Pressure or weight “…Sometimes as if I am under a giant metal press crushing my chest and throat, head” (Participant 28) “As if I’m lying in the middle of a road and a road roller keeps driving over me” (Participant 33) “I have a mental image of a large hand inside the base of my spine squeezing as hard as it can, relentlessly…” (Participant 97)

  33. Sub-theme:. Sharpness “Like a knife or broken glass being stabbed in my leg” (Participant 23) “Very sharp, jagged teeth searing into my neck like the jaws of a shark” (Participant 25) “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)

  34. Sub-theme: Burning Heat “like a red hot poker” (Participant 26) “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)

  35. Sub-theme: Electricity “Electricity running along wires, electric shocks…” (Participant 16) “…The pain down my leg is like a bolt of lightning” (Participant 97) “I have an image of an electric short circuit running down my legs!!” (Participant 93)

  36. Sub-theme: Vibration “Like a piano string being twanged” (Participant 13)

  37. Theme 2. Anatomical Representations of Damage • “…I think there is all this redness, inflammation, muscle damage around the herniated disk” (Participant 22) • “Bones grinding together” (Participant 32) • “The discs in my spine crumbling or grinding together causing my body to grind to a halt” (Participant 111)

  38. Theme 3. A Ball of Pain • “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” (Participant 1) • “My image looks like a large ball about the size of a tennis ball and it looks spongy and horrible” (Participant 14) • “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” (Participant 18)

  39. 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) • “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…” (Participant 22) • “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” (Participant 30)

  40. Theme 5. Expressions of distress (not images?) • “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” (Participant 4) • “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 9) • “Sometimes I just want to crash the car or just take all my tablets” (Participant 34)

  41. Theme 6. Verbal descriptions of sensory qualities of pain (not images?) • “It’s a shooting pain plus pins and needles” (Participant 7) • “A persistent gnawing pain that never goes away” (Participant 29) • “That unbearable pain in the forehead that comes when eating ice-cream too quickly, but the pain does not go away” (Participant 12)

  42. Theme 7. Unclear • “My image is like seeing myself going up like a balloon. I have lost 2 stone in 1 year and have started putting on weight…” (Participant 10) • “I see faces in the sky” (Participant 17)

  43. Limitations • Small sample size • Its difficult to measure: some of the descriptions appear more imagery like than others • Not full qualitative analysis (e.g. grounded theory)

  44. Limitations • Measurement: DAPOS – possibly not a good measure of anxiety (3 items)

  45. 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

  46. Limitations • Still need to develop a good measure of imagery • These studies bring us a few steps closer to developing imagery measures

  47. 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

  48. 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

  49. 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

  50. Next steps • Continue working on imagery conceptualisation • Construct good measures • Examine relationships between imagery measures and other constructs

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