Berna et al. Figure 1 Cognitive behavioral therapy (CBT) for- mulation of the potential role of mental imagery in chronic pain. Triggers, such as pain or a reminder of the pain, evoke the image, which is linked to strong emotions, a negative interpretation (meaning), and avoidance. All this leads to a stronger/more negative experience of pain, and an increased likelihood of new occurrences of the image. The descriptions of patients’ most relevant mental images in Table 1 are organized along this vicious cycle’s structure. was Asian. Eight women had a diagnosis of endometrio- sis or adenomyosis, which they considered to explain part or all of their symptoms. Two women regarded their pain as unexplained. Self-reported somatic comorbidities were: rheumatoid arthritis (N = 1), ﬁbromyalgia (N = 1), irritable bowel syndrome (N = 2), chronic shoulder pain following a traumatic injury (N = 1), and polycystic ovary syndrome (N = 1). Most reported abdominal surgery either for a caesarean (N = 3), for chronic pelvic pain- related investigations or treatments (N = 5), or for a gastric hernia (N = 1). A number of participants met cri- teria for the current axis I diagnoses: panic disorder (N = 3), depressive episode (N = 2), speciﬁc phobia (N = 1). History of comorbid lifetime disorders was as follows: past depression (N = 2), panic disorder (N = 2), bulimia (N = 1). None met diagnostic criteria for posttrau- matic stress disorder. 1088 Measures Cognitions about Pain Interview The cognitions about pain interview was based on previous mental imagery studies [21,36–38]. Verbal thoughts and mental images were ﬁrst deﬁned with everyday examples and then explored separately, in a pseudo-randomized order across participants. For the purpose of the current article, the mental imagery interview is described in detail; the in- terview about verbal thoughts followed the same structure. Participants were ﬁrst asked an open-ended question: “We would like to know more about what you think when you are in pain. Can you think of any images that pop into your mind at that time?” Then they were asked whether they had experienced any image in any of 10 predeter- mined categories (e.g., “a time when your body was hurt,” “the pain as a thing or an object”). The participant gave a short description for each reported image. Care was taken to exclude descriptors used to communicate the nature of the pain to others but which were not spontaneous cog- nitions the patient would actually experience when in pain. Hence, if a metaphor was reported (e.g., “It feels like a ﬁre”), participants were asked if it was a mental image or a descriptor. Responses in the category of “an image that makes you feel safe or better,” plus any other image described as positive, were computed as “coping” images. Participants were then asked to choose the “most sig- niﬁcant” mental image among those they had identiﬁed (i.e., the one they felt was most relevant to their pain, or the one they had most often when in pain). The most signiﬁcant image was then explored in detail for content (“What is the image of?”), triggers (“Do you know any triggers for it?”), the type of emotion associated with it, the meaning it had for them (“What does it mean to you?”), the activities impaired by it (“Does it make you want to avoid certain activities? Which activities?”) as well as any behavior increased by it (“What does it make you want to do?”). The most signiﬁcant image was then rated on bidirectional 10 cm visual analogue scales (VAS) for the emotional valence (ranging from very negative, -10, to neutral, 0, to very positive, +10), and for the emotional impact (“How does it make you feel?”, from very much worse, -10, to neutral, 0, to very much better +10). In addition, unidirec- tional 10 cm VAS (ranging from 0, not at all, to 10, extremely or always, depending on the question) assessed both the cognitive (wishes for the image not to be there and worry) and the behavioral avoidance asso- ciated with the image as well as any behaviors it increased. The corresponding data was collected on verbal thoughts in order not to bias the responses toward one type of cognition.