My body is not working right: a cognitive behavioral model of body image and 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 encodemovement and position of the body. Lotze and Moseley 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. 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, 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. 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. 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.