“Knees being set on fire”: A qualitative study exploring the impact of intrusive mental imagery on chronic pain patients

Rita De Nicola, Simon E. Blackwell, Edward Hirata, Jo Daniels

Research output: Contribution to journalArticlepeer-review


Chronic pain is common and debilitating, and recommended treatments are only moderately effective for pain relief. Focus has shifted to refining targets for change within psychological therapy to improve pain management. Evidence has shown the role of intrusive images in many psychological disorders. However, only a few studies have advanced our knowledge of the presence and impact of mental imagery in chronic pain. This exploratory study aimed to increase our understanding of how people with chronic pain perceive intrusive visual images to influence their daily life. The study employed a qualitative design, using semi-structured interviews to explore the content, emotional valence, cognitive and behavioural impact of pain-related visual images of ten participants with self-reported diagnosis of chronic pain. Data analysis was conducted by performing an inductive thematic analysis. Three key themes were identified: (1) 'I start to create images in my head': pain-related mental images, which revolves around descriptions of participants' most significant visual image; (2) metaphors for pain, related to the imagery as a means to conceptualise and give meaning to the pain; and (3) With the pain comes the image: a companion to pain, which focuses on the role of intrusive images in the experience of pain. Results show that pain-related mental imagery appeared to be an intrusive, uncontrollable, and vivid cognitive accompaniment for many pain sufferers. The findings suggest that mental images may serve as an additional target in cognitive behavioural therapy to enhance individuals' cognitive, behavioural and emotional change. Key learning aims (1) To understand the role of mental imagery in the daily life of individuals with chronic pain. (2) To examine the impact of intrusive images on the emotions, cognitions, and behaviours of people with chronic pain. (3) To consider clinical implications for CBT interventions targeting pain-related mental images to manage chronic pain.

Original languageEnglish
Article numbere19
JournalCognitive Behaviour Therapist
Early online date3 Jun 2024
Publication statusPublished - 3 Jun 2024

Data Availability Statement

The data that support the findings of this study are available from the corresponding author,
J.D., upon reasonable request. The data are not publicly available due to them containing information that could compromise
research participant privacy and consent.


  • Chronic pain
  • Cognitive behavioural therapy
  • Mental imagery
  • Qualitative study design

ASJC Scopus subject areas

  • Experimental and Cognitive Psychology
  • Clinical Psychology

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