What does chronic pain look like?BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4035 (Published 05 June 2019) Cite this as: BMJ 2019;365:l4035
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We read this article with interest. The use of example imagery to help patients describe their pain experience should significantly improve doctor-patient communication. Padfield, Chadwick and Omand explored the same clinical tool in their engaging perspective piece . They describe a therapeutic clinician–patient–image triangle and showcase the revealing patient narratives generated. One patient selects an image of a broken link in a chain and uses this to discuss her feelings of loss of family relationships. Padfield et al. have also undertaken a thought-provoking multi-disciplinary analysis of the use of imagery in pain consultations .
We also wanted to highlight to readers the concept of pain imagery, whereby people living with pain can experience intrusive imagery associated with their pain. Pain imagery has been reported in various chronic (and acute) pain conditions [3-6], with prevalence ranging from 23-100% [3,4].
Some may argue that imagery linked to pain is merely metaphorical, to describe painful sensations. However, as countered by Berna, Tracey and Holmes, this imagery is often uncontrollable, intrusive, and some people barely realise the imagery they experience are cognitions and not fact . Berna, Tracey and Holmes argue that pain imagery can “incorporate symbolic or real elements of the patient’s individual pain experience” .
No longer a visual metaphor to aid dialogue, pain imagery can interfere with daily life  and worsen mood [3-6]. Imagery content often falls into different themes (such as pain as an attack ), which may provide new insight into a patient’s pain experience and act as a springboard for further exploration. Coping imagery also exists. In one study, eight out of the ten women interviewed with chronic pelvic pain who experience pain imagery also experience coping imagery .
Pain imagery may provide a novel target for imagery-based psychological therapies, such as cognitive behavioural therapy [4,7,8].
For more on pain imagery, we recommend Berna, Tracey and Holmes’ article, which includes a case example where the patient experiences both negative pain imagery and positive coping imagery  and Berna’s chapter in Meanings of Pain .
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2. Padfield D, Omand H, Semino E, et al. Images as catalysts for meaning-making in medical pain encounters: a multidisciplinary analysis. Med Humanit 2018; 44: 74-81. https://mh.bmj.com/content/44/2/74
3. Gillanders D, Potter L, Morris PG. Pain Related-Visual Imagery is Associated with Distress in Chronic Pain Sufferers. Behav Cogn Psychother 2012; 40(5): 577-89. https://doi.org/10.1017/S1352465812000045
4. Berna C, Vincent K, Moore J, et al. Presence of Mental Imagery Associated with Chronic Pelvic Pain: A Pilot Study. Pain Med 2011; 12(7): 1086-93. https://doi.org/10.1111/j.1526-4637.2011.01152.x
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6. Philips HC. Imagery and Pain: The Prevalence, Characteristics, and Potency of Imagery Associated with Pain. Behav Cogn Psychother 2011; 39(5): 523-40. https://doi.org/10.1017/S1352465811000282
7. Berna C, Tracey I, Holmes EA. How a better understanding of spontaneous mental imagery linked to pain could enhance imagery-based therapy in chronic pain. J Exp Psychopathol 2012; 3: 258–73. https://doi.org/10.5127/jep.017911
8. Holmes EA, Arntz A, Smucker MR. Imagery rescripting in cognitive behaviour therapy: Images, treatment techniques and outcomes. J Behav Ther Exp Psychiatry 2007; 38(4): 297–305. https://doi.org/10.1016/j.jbtep.2007.10.007
9. Berna C. Mental Imagery in Chronic Pain: An Access to Meaning Beyond Words. In: van Rysewyk S, ed. Meanings of Pain. Cham, Switzerland: Springer International Publishing; 2016. p. 267-80. https://doi.org/10.1007/978-3-319-49022-9_16
Competing interests: No competing interests