that I get an injection of a painkiller.”; and “I see my husband. He gives me support.” These examples sum- marize the coping imagery described by the participants, which one could describe in three categories (post-hoc): “allegoric treatment of an object symbolizing pain,” “imaginary treatment applied to the body,” and “suppor- tive person.” Verbal Thoughts For eight participants, the most signiﬁcant verbal thoughts were reported as being directly linked with a mental image. For example, for participant 5, the most signiﬁcant verbal thought was “I am not being listened to,” and it was associated with an image of an operation she had undergone. Discussion Interviews were performed on a small sample of patients (N = 10) with one speciﬁc chronic pain syndrome (chronic pelvic pain). This exploratory study represents a ﬁrst step in investigating a neglected yet potentially important form of cognition in pain—mental imagery. On average, the group had mild pain intensity but severe interference due to pain, high catastrophizing, and typical trait imagery ability. That all patients reported negative mental imagery associated with their symptoms, provides encouraging support for the importance of this rarely considered type of thought process in pain suffering. All interview responses were consistent with a classic CBT vicious cycle, whereby the negative imagery could amplify pain suffering (see Figure 1). The proposed vicious cycle is based on previous formulations using imagery [28]. While this is a hypothetical model, it is interesting to note that in an experimental context, images can contribute to fear conditioning [44]. Furthermore, abnormal memory forma- tion or extinction has been proposed to contribute to the pathological process underlying the chroniﬁcation of pain [45]. Images of difﬁcult memories associated with pain were common among the cognitions described by the patients in this study. This suggests that mental imagery could be a richer source of enquiry about patient’s expe- rience of pain, including their beliefs and fears, than purely verbal report. Interpreting these ﬁndings in a CBT framework could be helpful for developing new therapies; however, at this stage of research, we remain open to alternative explana- tory models. Further research should conﬁrm that these images have an emotional impact and are not merely visual representations of the pain facilitating its acknowl- edgment. In fact, all mental images contained visual elements, which is interestingly similar to ﬁndings in post- traumatic stress disorder [46], but other sensory modali- ties were also described. There has been some indication of imagery-based pain- related negative cognitions in previous research [4–6], however, with lower rates of occurrence. The method of the present study differed from the previous work, as a Mental Imagery Associated with Chronic Pain face-to-face interview focusing on the different forms of cognitions was performed, speciﬁcally in patients with chronic pain. A psychology-trained physician who was not in charge of the patients’ treatment conducted the inter- view. This might have helped the patients to disclose their cognitions. Patients with chronic pelvic pain often do not feel that physicians are taking their symptoms seriously [35]. Therefore, they might be worried such cognitions could affect how their doctor perceives them. Moreover, the sample presented here is very small and relatively homogenous. A similar approach has been taken in mapping out novel symptomatalogy in other clinical groups (e.g., suicidal ﬂashforwards and agoraphobia; [21,37]). Thus, following a wider research tradition in other disorders, this pilot interview study should be replicated in different pain conditions and larger populations of patients. Our hypothesis focused on negative pain-related cogni- tions, and the interview was setup to assess this. Inter- estingly, while all images considered as most relevant by the patients were of negative valence, some patients also reported spontaneous coping imagery. Similar ﬁnd- ings have been previously described in the context of acute dental pain [4] and in experimental pain settings [7,8]. Such coping strategies can provide control over pain in the experimental context [47]; however, it is not yet known if they have the same effect in chronic pain, or if they are dysfunctional and act as avoidance. This form of coping cognition warrants further exploration in the future. In conclusion, this exploratory study conﬁrmed that cog- nitions about chronic pain could indeed take the form of mental imagery (as suggested previously). Furthermore, the idiosyncratic contents of these intrusive images were described. The study is limited by its small sample size, yet it is able to conclude that spontaneous mental images do occur in chronic pain patients. Idiosyncratic intrusive negative imagery has hitherto been neglected in pain treatment. Yet, as in other disorders, such negative (pain related) cognitions may ﬁt a classic CBT vicious cycle, involving negative interpretations, emotions, and avoidance. If so, chronic pain patients’ own unique spontaneous mental imagery could represent a useful and speciﬁc target for therapy, as in other disorders [48]. However, the causal status and malleability of such imagery remains to be explored. The potential for treat- ment innovation targeting such imagery is of particular importance for future research given the poor relief pro- vided to chronic pain patients by currently available treat- ment strategies and the frequent comorbidity with emotional disorders. This research offers a promising ﬁrst step in this direction. Acknowledgments We would like to thank the patients who agreed to participate in this study and generously shared their experience. 1091