Intended for healthcare professionals

Letters Visualising chronic pain

Intrusive imagery associated with pain

BMJ 2019; 366 doi: (Published 10 September 2019) Cite this as: BMJ 2019;366:l5459
  1. Christopher J Graham, online education officer1,
  2. Shona L Brown, clinical psychologist2,
  3. Katy Vincent, senior pain fellow3,
  4. Andrew W Horne, professor of gynaecology and reproductive sciences4
  1. 1Royal College of Physicians of Edinburgh, Edinburgh EH2 1JQ, UK
  2. 2Department of Clinical Psychology, NHS Lothian, Edinburgh, UK
  3. 3Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
  4. 4MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
  1. c.graham{at}

Warren describes the use of example imagery to help patients describe their pain experience, which should substantially improve doctor-patient communication.1 Padfield and colleagues explored the same clinical tool in their engaging perspective piece.2 They describe a therapeutic triangle linking the clinician, patient, and image and showcase the revealing patient narratives generated. One patient selected an image of a broken link in a chain and used this to discuss her feelings of loss of family relationships. Padfield and colleagues have also undertaken a thought provoking multidisciplinary analysis of the use of imagery in pain consultations.3

We want to add that people living with pain can experience intrusive imagery associated with their pain. Pain imagery has been reported in various chronic (and acute) pain conditions,4567 with prevalence ranging from 23% to 100%.45

Some might argue that imagery linked to pain is merely metaphorical, to describe painful sensations. But, as countered by Berna and colleagues, this imagery is often uncontrollable, intrusive, and some people barely realise that the images they experience are cognitions and not fact.8 Berna and colleagues argue that pain imagery can “incorporate symbolic or real elements of the patient’s individual pain experience.”8

No longer a visual metaphor to aid dialogue, pain imagery can interfere with daily life6 and worsen mood.4567 The imagery falls into different themes (such as pain as an attack), which might 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 of 10 women with chronic pelvic pain who experienced pain imagery also experienced coping imagery.5

Pain imagery might provide a novel target for image based psychological therapies, such as cognitive behavioural therapy.589

We recommend Berna and colleagues’ article, which includes the example of a patient who experiences both negative pain imagery and positive coping imagery,8 and Berna’s chapter in Meanings of Pain.10


  • Opinions expressed are the authors’ own. They do not necessarily reflect the view of the Royal College of Physicians of Edinburgh (CJG).

  • Competing interests: None declared.


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