about pain in the form of mental images have rarely been explored in clinical populations. Mental images are cog- nitions with sensory-perceptual qualities, as opposed to thoughts, that is, thinking in words. These sensory quali- ties, while often visual, can involve any modality such as smell, touch, taste, and hearing. No speciﬁc measure has been developed to assess mental images in patients suffering from pain and we know little about their occurrence. Very few studies have speciﬁcally investigated spontane- ous mental imagery linked to pain symptomatology. Chaves and Brown [4] interviewed 75 patients about verbal thoughts and imagery experienced during acute dental pain: 15% of the patients experienced mental imagery either as a coping strategy, or as a form of cata- strophizing. A postal questionnaire study of 83 patients with chronic pain concluded that 24% of respondents reported images linked to their pain [5]. In this study, the patients reporting imagery were more anxious and depressed than those who did not. A third study investi- gated images associated with chronic pain in patients suffering from irritable bowel syndrome, before and after hypnotherapy [6]. Out of 109 patients, 48.6% reported a mental image of their pain. The report of an image was associated with anxiety symptoms, but not with depres- sion, quality of life, or symptom severity. In summary, the little clinical research to date suggests that both negative and positive cognitions about pain could take the form of mental imagery and that negative imagery may be linked with emotional suffering [4–6]. Despite some studies describing the coping imagery experienced in the context of acute pain [4,7,8], little is yet known about the contents and use of coping cognitions in the form of images in chronic pain. In fact, in that context, widely employed scales such as the Coping Strategies Questionnaire do not make a distinction between verbal thoughts and mental images, hence not allowing these to be identiﬁed and studied separately [9]. There is a wider literature on hypnosis and therapeutic imagery, which describes the exploration of imagery for pain relief [10]. In this therapeutic approach, patients are brought to focus on an image of their pain while they are in a relaxed or hypnotic state and modiﬁcations to this image are suggested (e.g., [10,11]). However, the focus is more on the effects of creating or exploring and modifying an image representing pain, than on the description of the images, or their potential presence outside of these thera- peutic sessions. A body of work from psychology suggests that cogni- tions in the form of imagery could be of importance in chronic pain. Mental images are a form of cognition with a more powerful impact on both negative and positive emotion than words [12,13]. We know that mental imagery recruits similar brain regions as those involved in real perception [14]. Moreover, compared with verbal thought, imagery has a stronger impact on behavior, learning, memory, and beliefs (see [15] for a review). Mental Imagery Associated with Chronic Pain Having negative pain-related verbal cognitions has been shown to impact on chronic pain outcomes (e.g., [16]). Thus, negative images related to pain, compared to negative verbal thoughts, would be predicted to have a stronger impact on the pain experience, the emotions associated with it, the behavioral outcomes, and so forth. While this type of cognition was recognized in the early days of CBT [17], research on mental imagery has only recently expanded. It has now been shown to be an important process in a range of mood and anxiety dis- orders including post-traumatic stress disorder and depression [18–28]. Interestingly, chronic pain is often associated with depression and anxiety, and they seem to reinforce each other [29,30]. Hence, negative mental imagery, if it occurred, would be predicted to participate in a negative vicious cycle amplifying pain and negative emotions. To illustrate this, Clark’s model of anxiety [31] was adapted in the current work, with an emphasis on the role of imagery [28]. Chronic pelvic pain is described as pain in the pelvis lasting for at least 6 months, not occurring exclusively with men- struation or intercourse and not associated with pregnancy [32]. It has an incidence comparable with that of back pain or asthma [33]. It has been demonstrated that the presence or absence of a causal diagnosis in this condition does not have an impact on psychological distress and that the levels of anxiety and depression are similar to other chronic pain populations [34]. Patients were therefore recruited from a specialized tertiary referral clinic treating and inves- tigating chronic pelvic pain in women [32,33,35] at the Nufﬁeld Department of Obstetrics and Gynaecology in Oxford, thereby providing a relatively homogenous patient group in terms of gender and pain location. The primary aim of this study was to assess if a group of women with chronic pelvic pain reported experiencing mental imagery related to pain, in addition to their verbal thoughts about pain. While our focus was on negative imagery as a potential treatment target, we were also curious as to whether any spontaneous positive (coping) imagery might occur. Furthermore, if this were the case, we sought to describe the nature of such imagery. A CBT framework was used by considering mental images as a form of cognition (thought with different properties than verbal ones) (Figure 1). Patients and Methods Patients Patients treated at the Chronic Pelvic Pain Clinic of the Nufﬁeld Department of Obstetrics and Gynaecology in Oxford were referred by their physician. Participants were reimbursed for their time plus transportation. The study was approved by the Oxfordshire Research Ethics Com- mittee of the National Health Service (OXREC ref. 08/H0605/76). Ten women (mean age 36.20 standard deviation [SD] 6.96 years) participated. Nine were Caucasian and one 1087