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My body is not working right: a cognitive behavioral model of body image and chronic pain

Sündermann, Olivera,*; Flink, Idab; Linton, Steven Jamesb

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doi: 10.1097/j.pain.0000000000001822

1. Body image and relevance for chronic pain

Chronic pain profoundly affects several areas of a person's life. One facet which has received relatively little attention is the relationship between a person's perception of their body—ie, their body image (BI)—and their pain experience.

Within the pain literature, BI is mostly understood from a sensorimotor perspective where BI refers to implicit cortical maps that encode movement and position of the body. Lotze and Moseley21 defined BI as the conscious experience of how one's body feels to its owner and proposed that BI is a dynamic construct maintained by ongoing tactile, proprioceptive, and visual input, which can be modulated by memory, belief, and psychosocial factors. An important assumption is that pain influences how patients perceive their body (through sensorimotor neurological processes), but the reverse is not highlighted, ie, how one's BI may influence one's experience of pain. The psychological literature defines BI similarly but emphasizes the multifaceted experience that entails imagery, appraisals, feelings, and behaviors related to one's body, with a particular focus on appearance.3,11 The same processes are involved in pain, with the addition of functional limitations, which in turn may influence BI. We argue for broadening the conceptualization of BI in chronic pain, with a stronger focus on the bidirectional link between BI and pain.

Although BI distortions are well known in clinical psychology, less is known about whether BI distortions play a role in the experience of chronic pain. There is cause, however, to believe this because how we view our body and our pain is influenced by several internal and external factors including psychological processes involved in both chronic pain and BI disorders. Because BI disturbances (eg, eating disorders and body dysmorphic disorder) revolve around perceptual exaggerations of particular aspects and areas of the body, people with such problems might experience pain differently, eg, more intensely. Furthermore, since pain is known to alter thought patterns and cognitions,2,35,36 this might also contribute to changes in BI. For example, hypervigilant scanning of the pain area may lead to perceptual distortions of that body area and preoccupation with it. Similarly, because both pain and BI distortions can trigger intense negative emotions (such as anger, fear, and shame), these may contribute to mutual maintenance of these problems.1,19 Finally, recent theoretical advances in the pain literature on mind–body interactions also propose that the experience of pain can alter nonpain perceptions, including distorted body perceptions.31

This article reviews the literature on the relationship between BI and pain, and incorporating ideas from psychopathology, we propose a cognitive behavioral model emphasizing the bidirectional links between distorted BI and chronic pain.

2. Biomedical perspectives on body image distortions in chronic pain

Fifteen years ago, Pruzinsky published his clarion call for more attention to the vastly neglected field of BI in people with medical conditions. Many medical problems have detrimental effects on the person's BI. Pain, loss of physical function, mobility, and sensory functioning can all change how we experience our bodies. Pain sensations likely require BI adaption, and the idea that pain is associated with BI changes is not new. Most research in this field investigated neurological correlates and cortical reorganizations of BI in pain patients, but not the reverse, ie, how BI changes affect the pain experience.

Patients with complex regional pain syndrome (CRPS) experience a distorted BI, manifested in cortical adaptations to the pain. For example, CRPS type 1 involves shrinkage of S1 representation and, patients often perceive the affected limb as swollen or expanded.23,26 Decreased S1 representation correlates with pain intensity,13 and S1 reorganization normalizes when CRPS resolves.22 Although cortical BI disruptions are related to pain, there is no evidence of a causal relationship.21 CRPS patients often experience bizarre perceptions of discreet parts of the limb missing or distorted.18 Although “neglect-like symptoms” such as foreignness of the affected body part are common in CRPS,18,25 unlike neurological neglect patients, CRPS patients usually have insight into their BI distortions.18

Patients with phantom limb pain also experience BI distortions7 and commonly report perceptual experiences of their missing limb as enlarged, swollen, partially missing a segment, or stuck in a certain position.9 Reorganization after deafferentation occurs in S1, the extent of the reorganizational shift correlates with pain intensity.7

Pain-related BI distortions may also be reflected in tactile acuity (TA), mislocalization of tactile stimuli, and patient drawings of the painful area. Reduced TA, presumably reflecting cortical alterations,6,22,33 occurs in most chronic non-neuropathic pain patients (eg, arthritis, CRPS, and chronic low back pain), with most clients showing deficits in accurately drawing their painful area,27,28 and often corrective changes in drawings are associated with pain reductions.14 Although TA, which refers to nonpainful stimuli, is often impaired in chronic pain patients, the perception of painful stimuli can at the same time be enhanced.12 Hyperalgesia (increased sensitivity to pain) and allodynia (pain triggered by a stimulus that usually does not cause pain) seem most common in neuropathic pain conditions12 and may also contribute to BI distortions in this patient group.

3. Psychological perspectives on body image distortions in chronic pain

Research on the interaction between BI and chronic pain, while sparse, provides intriguing insights supporting a bidirectional link. Emerging evidence points at BI concerns being associated with chronic pain,16,17 reflected in perceptions of pain characteristics, intensity, and distress.23,30 In a recent qualitative study,30 we examined BI distortions and concerns in a sample of 7 patients with musculoskeletal pain and found that all reported appearance concerns, often related to pain-induced negative mood and reduced functioning.

The intricate relationship between BI concerns and chronic pain has several layers. Patients may be concerned that their pain or their injury is not observable to others,4 or that they appear as older than their actual age,8,30 both concerns exacerbating suffering. Evidence is emerging that BI is related to functioning.8,17,30 Levenig et al.17 found that chronic low back pain patients reported a more negative BI than healthy controls, and, interestingly, level of disability correlated with a negative BI.

Finally, BI is related to adaptation to pain. Once injured, a patient must adjust to the new conditions and how one perceives the body is likely amended. This may in turn be associated with the development of certain coping strategies. In a rare examination of coping strategies for BI issues, patients reported BI-coping strategies that involved paying special attention to their appearance through grooming and dressing routines, and the opposite, ie, avoidance of mirrors or weighing scales due to a dislike of their painful bodies.30 However, research on BI in chronic pain is haphazardly and thinly sowed, which greatly restricts drawing firm conclusions. To this end, a model is needed to guide a systematic approach.

Taken together, there is extensive evidence for the relation between BI and pain from medical–biological perspective. Yet, little research has turned to the psychological experience of BI in pain and their bidirectional relationship. Below, we argue that it is important to highlight this neglected area of pain research and present a cognitive behavioral model of how pain and BI are interrelated.

4. A cognitive behavioral model of body image and chronic pain

The cognitive behavioral framework is well suited to conceptualize the intricate relation between BI and chronic pain because it identifies developmental and maintaining processes that can be tested and targeted in clinical practice and research. The model (Fig. 1) is heuristic and based on preliminary evidence and clinical observations from our work with chronic pain patients. In essence, the model proposes that maladaptive pain-coping strategies contribute, over time, to a distorted BI in 3 ways: First, the perception of one's body (image of self); second, negative appraisals of the perceived image (eg, “My body is wrecked”; “I look old and tired”; and “My broken body is unattractive”), which, third, triggers negative emotions (eg, sadness, anger, shame, and anxiety). In turn, a negative BI drives unhelpful BI-coping strategies (eg, avoidance of mirrors, or social contacts; comparisons, grooming) that maintain the negative BI and adversely affect the pain experience. Two key aspects of the BI are believed to be affected: (1) perceived appearance and (2) perceived loss of function and mobility. This is an important expansion of previous cognitive behavioral models of BI,3,34 which predominantly focus on the person's appearance concerns, including weight and shape worries. We argue that the actual and perceived loss of function, mobility, limitations, and appraisals of these is an important part of the BI and should, therefore, be included in the assessment and conceptualization of chronic pain patients.

Figure 1.
Figure 1.:
The cognitive behavioral model of body image (BI) and chronic pain. Over time maladaptive pain-coping strategies (eg, catastrophizing, avoidance of movements) lead to changes of the person's BI: altered appearance perception and perceived loss of function and mobility through distorted imagery of one's body, which is negatively appraised (eg, “My body is old, wrecked! I am weak, unattractive”), triggers negative emotions (eg, sadness, anger, and shame). Unhelpful BI-coping strategies (eg, mirror checks and avoidance of social contacts) maintain the negative BI and exacerbate the pain experience.

4.1. Unhelpful pain coping as a precursor of body image problems

Chronic pain patients commonly cope through safety and avoidance behaviors that usually have unintended consequences of maintaining or exaggerating the pain and may also lower their level of functioning and contribute to loss of mobility.15,35 For example, a patient with chronic back pain may avoid any movements due to a fear of triggering or worsening the pain.24 Over time, the person's mobility radius shrinks and may lead to unwanted negative secondary effects such as weight gain, isolation, or loss of muscle mass. Generally, coping strategies that are avoidant in nature are associated with more suffering and poorer adaptation while acceptance and control strategies are helpful.5,32

4.2. Imagery, appraisals, and body image–coping behaviors

Pain patients have BI concerns,17,30 but unlike people with BI disorders such as body dysmorphic disorder who experience distorted imagery of their disliked feature,29 BI distortions in chronic pain patients seem more characterized by a perceived loss of function. For example, pain patients experience unrealistic imagery of their bodies as appearing old, handicapped, or frail, particularly if they engage in dysfunctional pain-coping behaviors conducive of such images, eg, avoidance of movements, staying in bed, or hunching over.20 Our model proposes that imagery can consist of aspects of appearance and perceived function. For example, function-related imagery may consist of images of the person looking old and stooping down. Appearance-related imagery may consist of images of the painful spot (eg, neck), larger parts of the body (eg, upper torso), or the entire body.

A common feature of cognitive models is the central aspect of appraisals. We propose that idiosyncratic BI appraisals in chronic pain are meaningfully linked to BI-coping behaviors and emotions. For example, a pain patient with leg stiffness and function-related imagery of not being able to move may appraise this image as “I am crippled,” triggering shame and anxiety, and therefore avoiding movements. Equally, a patient hunching over, may appraise her image as “I am old and frail,” suffer from shame and sadness, and subsequently avoid social activities. A CRPS patient experiencing imagery of his swollen hand, and appearance-related appraisals of “I look defective, and ugly,” is likely to camouflage or cover his hand or may unfavorably compare himself. These BI-coping strategies have unintended consequences such as preventing disconfirmation of negative beliefs, increasing rumination, worry, and catastrophizing (“I will never heal”), selectively attending to symptoms, reduced social activities, and limited positive reinforcement, thereby maintaining the negative BI and pain experience or worsening them. For example, avoidance of movement, due to fear of pain, but also due to fear of judgment from others, can lead to further weight gain, or loss of muscles, thus keeping the person stuck in a vicious cycle of poor BI, pain, and dysfunctional coping behaviors. Importantly, the model also hypothesizes that the experience of a negative BI may directly motivate the person to engage in dysfunctional pain-coping behaviours such as overactivity or behavioural endurance10 in an attempt to establish a more positive BI (feeling young, fresh, and fit), thus ignoring any pain signals for a break and thereby worsening the pain problem, which in turn may feed back into a negative BI.

BI appraisals are also believed to depend on premorbid beliefs, ie, beliefs they were holding before the pain onset. This involves overvaluation of and investment in the importance of appearance and functioning, which can either buffer or compound the adverse effects pain has on the person's BI. For example, a person holding firm beliefs about the importance of youthfulness and fitness for attractiveness is likely to appraise pain-induced BI changes as more detrimental than someone who is less invested in such appearance beliefs. Equally, a person who is less invested in needing to look good or function well is likely to experience a more positive BI.

5. Clinical and research implications

Conceptualizing the psychological experience of BI in pain has implications for research and clinical practice. Our model is inspired by clinical observations and preliminary research and thus requires further scientific scrutiny. Future research may examine the hypothesized relationships of the different components: First, ineffective pain coping (eg, avoidance of movement and catastrophizing) is believed to precede a negative BI, while this would not be expected for effective pain coping (eg, acceptance). Subsequently, appearance-related and function-related imagery and appraisals are believed to be threat-based and related to perceived limitations (“I look limp, old, unattractive”) and thus lead to negative emotions (eg, shame, anger, and sadness), which in turn bring on unhelpful BI-coping behaviors (eg, mirror checking and fixing behaviors). Longitudinal studies can investigate the sequential development of pain and BI concerns. Experimental studies can examine the predicted relations between the different components of the model, eg, that maladaptive BI coping adversely affect the person's pain and that pain-related cognitive and attentional processes (eg, scanning the body) perpetuate and/or exacerbate the pain and contribute to a distorted BI. Future studies should clarify the directionality between pain and BI to establish how these 2 experiences interact and affect the person. Despite the early stage of this research, there are important considerations for clinical practice. A psychological assessment should cover the persons' experience of their (changed) BI, especially in relation to “struggling” with adaption to the pain, and how limitations and reduced function are perceived, appraised, and coped with.

6. Conclusion

BI adaptions are common in chronic pain, but the pain literature has mostly described BI in terms of cortical alterations. Here, we argue for a broader 2-way conceptualization of BI and chronic pain. The model proposes that ineffective pain-coping behaviors, over time, adversely affect the person's BI and that, in turn, BI changes shape one's experience of pain and functional limitations. The cognitive behavioral model of BI and chronic pain can account for the psychological experience resulting from the interplay of BI changes and perpetuating pain- and BI-coping behaviors. We hope that the model sparks an interest in this underdeveloped yet relevant pain field, and we have confidence that a better understanding of the interplay between BI and chronic pain improves the care of patients through targeting BI distortions and related coping strategies that have previously been overlooked.

Conflict of interest statement

The authors have no conflicts of interest to declare.

Supplemental video content

A video abstract associated with this article can be found at


This article was made possible through a grant, which the authors acknowledge with gratitude, from STINT, the Swedish Foundation for International Cooperation in Research and Higher Education, Stockholm, Sweden.


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