A prospective diary study of chronic pain-related intrusive mental imagery: "trolls climbing up my spine with ice axes" and other vivid images.

People with chronic pain can experience intrusive mental images (IMI) related to pain, that is, cognitions in the form of sensory-like experiences without actual sensory input. Previous retrospective studies suggested that such images are prevalent, associated with strong emotions, and contribute to pain maintenance. We prospectively investigated pain-related IMI occurrence and characteristics in patients with chronic secondary postsurgical or posttraumatic pain using electronic diaries, aiming to examine factors associated with pain reported after IMI. Of the 50 study completers, 35 (70%) reported pain-related IMI. They scored significantly higher on the Spontaneous Use of Imagery Scale ( t = -2.93, P < 0.001), PTSD Checklist for DSM-5 ( t = -3.98, P < 0.0001), and Hospital Anxiety and Depression Scale depression score ( t = -2.11, P = 0.045) than those without IMI. On average, patients experiencing IMI reported 6.5 images/week, with moderate vividness (mean 6.5/10), emotional intensity (mean 5.4/10), and pain after IMI (mean 6.0/10). Intrusive mental images were mostly of negative valence (81.6%). However, almost one-third reported coping images. Baseline pain measures correlated with IMI vividness, emotional intensity, and valence but not image frequency. Multilevel modelling indicated that IMI vividness, emotional intensity, and valence were significant predictors of postimage pain, with pain catastrophizing also emerging as a significant baseline predictor. Hence, IMI may interact with pain experiences through IMI characteristics. This prospective study highlights a high prevalence and frequent occurrence of IMI in chronic secondary pain and associations with pain following imagery episodes. These findings underscore a possible role for imagery-targeted therapeutic interventions.