Reimagining pain: the role of mental imagery in pain experience.

Mental imagery refers to the experience of internal perceptual experiences in the absence of external sensory input, such as seeing in the “mind's eye.” 42 , 54 Although often visual, mental imagery can involve multiple sensory modalities, 3 including auditory and haptics. There is substantial overlap in brain systems engaged during external sensory perception and internal mental imagery generation across primary sensory, parietal, and frontal cortices. 15 , 42 , 53 Mental imagery is theorised to support mental simulation functions that “run” mental models of hypothetical scenarios in an “as-if-real” manner, emulating not only what a scenario would involve but also how it could unfold and how it may feel to experience it. 10 , 24 , 50 Scene-based mental imagery underpins a range of higher order reconstructive memory and future thinking processes, 26 giving rise to our capacity to relive events from the past and preexperience hypothetical future ones. 1 , 63 As such, mental imagery of emotional experiences can evoke emotional and motivational responses at subjective and neurophysiological levels. 10 , 32 , 35 , 40 , 43 Importantly, it appears that scene-based mental imagery is what makes mentally represented events feel “real,” as without it, verbal descriptions of emotional events produce substantially reduced emotional and motivational responses. 39 , 45 , 76 This is consistent with research on emotional disorders, where vivid mental images of emotional events feel compelling and real, and they have greater emotional impact than verbal thinking. 33 , 40 , 54

One area where the link between mental imagery and pain is being studied is in the comorbidity between trauma and pain. Imagery-based intrusions can be associated with pain, such that the intrusive image amplifies or even induces pain and vice versa. 44 , 69 , 74 , 75 But what if this reciprocal relationship between imagery and pain extended beyond trauma? Research increasingly indicates that pain-related mental imagery is prevalent and clinically meaningful in the pain experience. Pain-related imagery is reported by 23% to 89% of people with chronic pain, i.e. pain that has been occurring for at least 3 months. 20 , 22 , 40 , 46 , 56 , 71 A strong relationship has been found between negative pain-related imagery and pain-related distress, anxiety, and depression. 14 , 20 , 22 , 23 , 56 Preliminary research suggests that pain-related mental imagery is associated with increased pain severity 56 , 70 , 71 and pain-related functional interference 70 , 71 but not necessarily broader health-related disability. 20 In particular, momentary increases in imagery frequency have predicted subsequent increases in pain severity and interference in youth with chronic pain, 71 indicating a role in the exacerbation or maintenance of poor pain outcomes. Pain-related mental imagery appears to be particularly salient in specific pain conditions such as pelvic pain and endometriosis, where 52% to 100% report pain-related mental imagery, 8 , 23 , 70 potentially due to the attribution of pain to internal organs, the use of medical imagery in clinical contexts, and the distinctive qualities of the pain. In people with endometriosis, rich anatomical imagery is commonly reported and has been linked to poorer pain outcomes 58 and distress. 23 Different facets of pain-related mental imagery may contribute uniquely to the pain experience, beyond its presence or frequency. Mental imagery vividness and emotional evaluation have been found to be associated with higher pain levels and worse pain interference in people with chronic pain 71 and endometriosis-related pain. 70 How individuals interpret their imagery also appears to be critical. Mental imagery has been found to interact with interpretation bias to predict pain interference in people with endometriosis. 70 Furthermore, Maxwell-Watts et al. 46 found that it was not the presence of pain-related imagery itself, but rather the negative appraisals of that imagery, that were associated with greater pain-related disability. Together, these findings suggest that pain-related mental imagery is not a unitary phenomenon. Instead, its impact on pain outcomes depends on a combination of how often it occurs, how vividly and emotionally it is experienced, and how it is interpreted.

Experimental research shows promise that mental imagery can modulate pain perception, with large and clinically meaningful effects in experimental settings. For example, imagining a glove as protection against electrocutaneous stimulation, 52 imagining a glove vs a lesion on the forearm during electrocutaneous stimulation, 17 and imagining acute heat stimuli as pleasant (alleviating hypothermia) vs noxious (steam from a clothes iron) 6 have all lead to changes in reported pain. These effects appear due to cognitive–affective mechanisms, independent of opioid (brainstem) pathways that tend to activate from expectations. 6 By contrast, preliminary evidence suggests that mental imagery alone is not sufficient to induce conditioned pain modulation, 9 although it remains to be tested whether mental imagery can affect the magnitude of conditioned pain modulation, once evoked. Experimental neuropsychological research has indicated that pain-related mental imagery can evoke discrete brain activation of regions involved in sensory and affective pain processing, despite the absence of somatosensory stimulation. Where participants were asked to imagine feeling experimentally induced pain they had previously experienced, an extensive network of pain processing areas was activated, including the bilateral anterior insula, anterior cingulate cortex, thalamus, and primary somatosensory cortex. 16 Similar pain region activation is also seen when participants were shown painful images and asked to imagine the pain associated with the image. 37 Furthermore, mental imagery of pain experienced from a first person perspective evokes greater pain and corresponding neural activation in interoceptive and emotional awareness regions (right anterior insula) than from a third-person perspective, 12 suggesting a clear link between pain-related mental imagery, subjective pain experience, and activation of pain-related brain regions.

Although pain-related mental imagery has been incorporated in some cognitive–behavioural frameworks and extensions of the fear avoidance model of pain, 73 these models are largely descriptive. For example, Jamani and Clyde 38 provide a framework in which images are situated alongside verbal cognitions in leading to pain-related fear following pain experience. In an adaptation of the fear-avoidance model of pain, 73 pain-related cognitions (thoughts and mental images) triggered by pain are proposed to drive a vicious cycle of pain-related fear, physiological arousal, and safety-seeking behaviours, increasing pain experience over time through deconditioning, depression, and disability. 38 Although these models argue for an important expansion of our conceptualisation of cognition beyond verbal thoughts, there is an implicit assumption of equity of status and function of thoughts and images. There is no indication of what specifically about negative imagery is problematic for pain, or how it might be leveraged to improve pain outcomes. Berna et al. 7 built on this cognitive–behavioural framework, seeking to differentiate between mental imagery that acts to amplify emotions and the subsequent cognitive appraisal or meaning assigned to those images or emotions. Pickup et al. 58 in a model of endometriosis pain took this argument 1 step further in proposing that mental imagery and associated cognitive appraisals or interpretations are part of an individual's attempts at making sense of their pain condition. In this model, negative imagery and its interpretation were seen as central, conveying distress, influencing identity (as enmeshed with pain and illness) and contributing to illness burden.

We propose a new broad theoretical framework that positions pain-related mental imagery as a key amplifier of the pain experience (Fig. 1 ), based on the previous contributions described. Pain regulation through imagery, mental appraisals, and emotion (PRIME) framework. Mental imagery is known to function as an amplifier of emotions, which can intensify emotional and physiological responses to internal and external stimuli. 29 , 35 We propose that negative pain-related imagery that is frequent, vivid, spontaneous, and distressing can lead to increased pain perception, pain distress, and pain interference. Consistent with cognitive–behavioural models, we propose that pain-related mental imagery is typically triggered by a precipitating event, which may be the experience of pain itself, or a physical, sensory, emotional, or cognitive reminder of pain (eg, movement, medical setting, pain-related thought). These triggers can elicit both verbal cognitions and intrusive mental imagery, which may occur in tandem. When imagery is present, it intensifies the emotional impact of cognitions by making them feel more salient and real. Imagery also gives rise to appraisals or interpretations of the meaning of the imagery or resulting emotion (eg, “This image means I'm getting worse,” “I can't stop seeing this”), further exacerbating distress. For example, a person experiencing pain may think “something must be seriously wrong,” although simultaneously visualising themselves previously incapacitated, imagining internal damage, or imagining a future scenario in which they are unable to work or socialise. 8 , 56 These scenario images serve to embody the verbal thoughts, intensifying emotional responses such as fear, distress, or hopelessness. This emotional amplification can lead to avoidance behaviours and increased pain interference, consistent with traditional cognitive–behavioural therapy (CBT) models. As well as scenario images, there may also be images of the internal pain itself, eg, a hook in one's vagina being yanked down 58 or intestines tearing or unzipping, 8 which could directly amplify the very experience of pain, through neuropsychological mechanisms. 6 , 52 Thus, negative pain-related imagery may not only shape how pain is interpreted and responded to, but also how it is directly experienced. Importantly, because imagery amplifies emotional valence (positive or negative), imagery also offers an opportunity to therapeutically attenuate pain.

Imaginal therapeutic techniques have been increasingly used to improve the efficacy of existing cognitive–behavioural approaches in a range of disorders, including posttraumatic stress disorder, generalised anxiety disorder, and social anxiety. 25 , 28 , 47 , 51 , 67 Guided imagery, generally with a focus on standardised positive or calming mental scenes, has been used in pain treatment as a standalone technique. Systematic reviews suggest potential benefits of guided imagery for chronic musculoskeletal, 61 nonmusculoskeletal, 62 and postoperative pain, 18 but the quality of evidence is generally low. Furthermore, 1 meta-analysis of 4 studies found nonsignificant effects on acute pain, 78 possibly due to considerable heterogeneity of intervention type and study design. More recent trials have shown benefits of guided imagery for acute procedural pain. 2 If guided imagery is conceptualised as a form of distraction through imagining pleasant visual scenes as a way to draw attention away from pain, it may show benefit for acute, rather than chronic pain, as has been found for distraction strategies in chronic pain more generally. 72 Guided imagery has also been incorporated alongside other techniques and therapies, 60 such as mindfulness, relaxation, psychoeducation, and breathing techniques, 18 although the specific contribution of mental imagery is rarely evaluated. Guided imagery is also often considered a key part of hypnosis, although there is some debate about whether it is necessary to induce mental imagery to achieve benefits within hypnosis. For example, some research has found that hypnosis was still effective when participants were asked to “let go of any image or thought that arises” (re), and there is mixed evidence regarding the association between mental imagery and hypnotisability. 21 Other research has found that hypnosis results in changes to mental imagery in irritable bowel syndrome and that these changes corresponded to treatment outcomes. 11 In the emotional disorders, imagery-based interventions have typically focused more on the specific negative emotional mental imagery experienced by the individual and efforts to change the meaning associated either with the original image or the interpretation or meaning attributed to that image, 59 rather than guiding through standardised scripts as is typically done with guided imagery. Such interventions may also prove to be more effective in pain. One technique that has demonstrated considerable efficacy as a stand-alone treatment for intrusive images in post-traumatic stress disorder (PTSD) and social anxiety, is imagery rescripting. 4 , 41 , 51 Imagery rescripting is a therapeutic technique whereby distressing mental imagery “scripts” are revisited and then modified to change their meaning and emotional impact. Only 1 published study has explored this technique for chronic pain. In 55 people with chronic pain who experienced pain-related mental imagery, imagery rescripting led to statistically and clinically significant reductions in pain intensity, emotional distress, and cognitive appraisals, outperforming mere repetition of pain imagery. 55 Indeed, 49% of participants reported no pain while viewing a rescripted image (compared to 11% for repetition). Although this was a proof-of-concept study that did not assess long-term outcomes, the reductions in pain were impressive and unusual in the pain literature. Larger studies, particularly in samples known to have high rates of negative pain-related imagery, are warranted. There are also several promising imagery-based interventions from mental health that have yet to be tested in pain populations, presenting an opportunity to better use imagery to facilitate pain management interventions. One such approach is imagery-enhanced CBT. Although Beck 5 emphasised the role of imagery in cognition in his early development of CBT, it is often underutilised in practice. In a Delphi study and accompanying systematic review of randomised controlled trials on chronic pain management, not 1 randomized trial in 10 years (N = 32) included imagery-enhanced CBT and none of the experts nominated imagery-based work as necessary or desirable. 65 Incorporating imagery into CBT can enhance emotional engagement and facilitate cognitive and behavioural change 30 , 48 , 64 , 68 because of its role in emotion amplification. Cognitive–behavioural therapy is considered the leading psychological treatment for chronic pain, 13 , 49 although the effect sizes are modest. 77 We argue that imagery may offer a way to boost outcomes by targeting emotion-laden appraisals more directly by using experiential imagery techniques to increase affect while challenging the content of images or their interpretation, 64 both of which are relevant for chronic pain treatment. Another approach that might add value in pain is imagery-enhanced cognitive bias modification for interpretation (CBMI). Cognitive bias modification for interpretation trains individuals to adopt more benign interpretations of ambiguous scenarios, and its efficacy is amplified when participants engage with scenarios using mental imagery. 31 , 34 Given that standard CBMI has improved chronic pain outcomes, 66 imagery enhanced versions, such as those under investigation in laboratory 19 and clinical settings, 57 may further improve pain outcomes. Another way to use an imagery technique is to use imagery competing tasks, as in the Imagery-Competing-Task-Intervention (ICTI). 27 , 36 This novel technique seeks to stop the image from being intrusive, so that it is less readily triggered and dampening the power of the image-based representation itself. The ICTI involves a very brief exposure to an index trauma image, followed by a visuospatial task (eg, playing Tetris with mental rotation). This technique has shown efficacy in reducing trauma-related imagery intrusions 27 , 36 and may be specifically relevant for people with pain-related trauma or intrusive pain-related imagery. In summary, although mental imagery interventions are well-established in mental health, their application in pain has not been rigorously tested. Preliminary research suggests that techniques such as imagery rescripting and guided imagery may reduce pain and distress in chronic pain and acute pain, respectively, although higher quality trials with longer follow-ups are needed. Further understanding of the mechanisms of mental imagery in pain is also required, as different interventions may be needed to target the image content, intrusiveness, or appraisals. For example, image content may be better targeted by imagery rescripting, imagery intrusiveness may be addressed through imaginal exposure or ICTI, and interpretations or appraisals may be better addressed through imagery-enhanced CBMI or CBT interventions.

Mental imagery is a powerful yet underrecognised component of the pain experience. We propose that pain-related mental imagery drives pain through simulating pain experiences and influencing threat-related interpretation, leading to emotion amplification and activating brain regions that overlap with pain affect and perception. Mental imagery therefore has the potential to either exacerbate or alleviate pain, presenting researchers and clinicians with a rare opportunity to markedly improve psychological treatments. Future research should prioritise testing and refining theoretical frameworks, advancing basic understanding of how pain-related mental imagery and its appraisal interacts with the brain's pain inhibition and regulation processes to influence pain perception and identifying temporal relationships between mental imagery characteristics and pain. Imagery-based interventions also need rigorous testing in pain populations, targeting specific features of pain imagery, such as content, intrusiveness, or appraisal. By integrating insights from cognitive neuroscience, experimental psychology, and clinical psychology, mental imagery may be harnessed to improve pain management.

The ARC does not have any authority over the research, data, or arising publications. E.A.H. developed the imagery-competing task intervention for intrusive memories and holds the trademark (ANEMONE) through Afterimagery.AB. E.A.H. receives book royalties from Guildford Press and Oxford University Press related to mental imagery and cognitive therapy, and receives occasional honoraria for conference keynotes and clinical workshops. The other authors have no conflicts of interest to declare.