Berna et al. Table 1 Description of patients’ self-identiﬁed most signiﬁcant image, with associated triggers, affect, meaning, and avoidance pattern N° Triggers Content of Image Associated Affect Associated Meaning 1. Pain, sex, sleep. I am being raped. 2. Pain, thinking and talking about pain. Malicious demons play around my pelvis, pushing, pulling and scratching. Repulsed, guilty, frightened, sick Bitterly amused A metaphor for the loss of control due to the pain. Pain is malicious, out to get me. 3. Pain, talking about Bright operating room pain. lights. Terrorized I’m going to die. 6. Pain, reminders of A gaping hole in my surgery or of abdomen, where my menstruation, uterus and ovaries exercise. were. It is much bigger than it can be in reality and impenetrable. 4. Pain, anxiety. 5. Pain, babies. 7. Pain. 8. Pain, social gatherings. 9. Pain. 10. Pain, movement. 1090 I see myself as a small curled up ﬁgure in a red pit, grasping upwards. Sad, helpless, anxious, tense In the hospital room, I Helpless and anxious Could this difficult see and hear being delivery explain the told I need a pain? caesarean. Something is wrong Avoidance of many with me, and I cannot activities. I want to ﬁx it. curl up and die. A little man jumping on my lower abdomen. He is the pain. My children are crying. Different things that could be happening inside me (e.g., my intestine is tearing or unzipping, there are ulcers in the bowel, my fallopian tubes are twisting). There’s a heavy, grey lead ball where it hurts. The weight is surprising, given its size. It’s dragging down, as if it was going to fall out of me, taking my insides out. Always sad, and at times angry or hopeful This hole is keeping the space open for my organs to come back. I have not accepted my surgery. Helpless The pain is winning. Panicky, anxious and I am not giving my guilty children a nice childhood. I am disappointing them. Panicky while pain increases, then fed up. They might have missed something. My pain is too important to be explained by my diagnosis. Disgusted, horriﬁed, revulsion Something is wrong. This gives a meaning to the pain. It brings up all my worries. I want to curl up in bed. Avoidance/Functional Impact Avoidance of triggers. I want to be a little girl, be looked after. Avoidance of physical activity. Avoidance by ﬁlling mind with a substitution image (see text). I cannot avoid the triggers. Avoidance of triggers, restricting shopping and social interactions. Avoidance of many activities. Avoidance by ﬁlling mind with image of a number. Avoidance of triggers and activities with children. Avoidance of many activities.