Standardized Questionnaires and Interviews These measures were used to characterize the popula- tion; however, they were not main outcomes of the study. The Brief Pain Inventory short form (BPI) [39] is a self- rating scale assessing pain severity and interference. It comprises a body map, on which the patient is expected to draw the localization of the pain. This map has been adapted for the gynecological pain context (http:// www.pelvicpain.org/resources/handpform.aspx). A rating for the worst and least pain over the last 24 hours (scales from 0–10) is given. The interference in different ﬁelds is rated on scales from 0 to 10. Given the speciﬁcity of chronic pelvic pain, additional items were created for “interference with sexual relationship(s)” and “relations with other people.” A mean of the different interference scales is computed. The Pain Catastrophizing Scale (PCS) [2] assesses verbal negative pain-related cognitions; it is a widely used scale that has shown predictive value in clinical populations [40]. The Spontaneous Use of Imagery Scale (SUIS) [41] is a self-report measure assessing the spontaneous use of mental imagery in everyday life. The Hospital Anxiety and Depression Score (HADS) [42] is a self-report measure that assesses anxiety and depres- sion in patients suffering from medical conditions. The Mini-International Neuropsychiatric Interview (M.I.N.I.) [43] is an interview that allows assessment of the presence or absence of a psychiatric condition, along the Diagnos- tic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Procedure Participants received the standardized questionnaires at home, which they had to complete and bring to the meeting. A physician (the ﬁrst author) led each of the interviews (approximately 2 hours). They were audio- recorded for supervision purposes. After giving written informed consent, the participant was asked about her pain (duration, cause, course over time, and treatments). The “cognitions about pain interview” was then com- pleted, followed by the M.I.N.I. interview. The participant was then debriefed, assessing if they needed advice on where to get help if they felt distressed. However, none of the women required such help. Results Patient Characteristics The mean duration of pain was 10.5 years (range 3–20 years). The mean worst pain score on the BPI was 5.44 (SD = 2.65) (this included two patients whose pain had signiﬁcantly decreased as effective treatment had been Mental Imagery Associated with Chronic Pain initiated); the mean BPI interference score was 6.94 (SD = 1.79), which would be considered severe [39]. The average catastrophizing score on the PCS was 27.56 (SD = 14.04), which is considered high [2]. The mean score on the SUIS was 2.97 (SD = 1.49), indicating a standard level of imagery ability [41]. The mean HADS scores were: 10.33 (SD = 4.39) for anxiety, 9.56 (SD = 4.64) for depression, and 19.89 (SD = 8.07) for the total score, suggesting the presence of both clinical anxiety and depression for some participants [42] (data incomplete for one participant). Experience of Cognitions Linked to Pain Negative Imagery All participants reported having mental images in addition to verbal thoughts linked to their pain. On average, patients reported 4.6 (SD = 1.43) different negative images. Each patient’s “most signiﬁcant” mental image content is described in Table 1, alongside the identiﬁed triggers, associated emotion, meaning, and avoidance behavior. For seven patients, the image gave a meaning to the pain, or was an allegory of what pain did to them, while for three patients, the image was a memory of an actual event. These memories seemed to be linked to the con- sequences of the pain (e.g., patient feeling she is failing in her role of mother) or to the original onset of pain (e.g., operating room lights). While some of the images con- tained different sensory modalities (e.g., auditory for par- ticipant 5, somatosensory for participant 10), all had some visual elements. The most signiﬁcant image had a negative emotional valence for all participants (M = -7.18, SD = 3.27). This image made the participants feel worse (M = -7.33, SD = 3.97); they wished that the image were not there (M = 5.73, SD = 4.29); they associated the image with worry (M = 6.24, SD = 3.10) and avoidance of activities (M = 7.90, SD = 3.00); the image was reported to increase pain-related behaviors (M = 7.34, SD = 3.00). Nine participants described cognitive or behavioral avoid- ance linked to their most signiﬁcant image (Table 1). Inter- estingly, for two participants, this took the form of a substitution mental imagery: for example, patient 3 described how bright operating lights were replaced in her mind’s eye by an image of a black soft cube, which she then tried to make smaller. Furthermore, seven partici- pants described avoidance of situations that were triggers of the image (such as reminders of a surgery, anxiety or potentially pain-increasing activities). Coping Imagery Interestingly, eight participants reported having one or more “coping” images when in pain (mean = 1.20, SD 0.92). For example, patient 1 described three spontane- ous coping images: “I put the pain into a box, but this is difﬁcult as no box is big enough.”; “I imagine that I grind an analgesic drug on my body, rubbing it in, or I imagine 1089