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Teaching folks to make connections with DIMs and SIMs

As part of pain education....

-We say things like “Pain is multifactorial.”

-We reference the influence of maladaptive beliefs.

-We define what pain is AND isn't

-We take the very first step to understanding


This is where many people stop.

You have farther to go!

Yes, pain is “multifactorial’ – but that knowledge may be meaningless unless one develops an awareness of what specific factors affect their pain.

How do you and your patient find out what factors are meaningful to them?

You teach them AWARENESS


Awareness is an inherent part of CHANGE.

We simply can’t change something unless we have a realization of it.

As simple as it sounds, the task itself can be challenging.

Awareness is a skill.

And skill acquisition requires learning over time. Much like motor skills, the initial development of awareness benefits from having a facilitator, with the long term goal of patient independence.

Sounds daunting? Don't worry.

Challenging tasks often benefit from a simple approach.

That's why I like using the concept of DIMs (danger in me) and SIMs (safety in me) developed by the NOI group to facilitate awareness.

In this post I use the symptom of pain but this approach can be used for other stress outputs such as tension/tightness, fatigue, dizziness, tingling and anxiety.

This is what I do:

Step 1. Explain DIMs and SIMs

Step 2. Provide examples

Step 3. Identify their own

Step 4. Correlate to symptoms

Step 5. Slay the DIMs & Create more SIMs

Step 6. Repeat and Reinforce

Step 1:

Get the conversation started with an EXPLANATION of DIMs and SIMs

DIMs and SIMs can be thought of as biomarkers for your brain-body’s perceived evidence for danger or safety.

Ugh, what the heck does that mean?

A biomarker is a measurable indicator of the physiological state of the organism.

In the case of DIMs and SIMs, they serve as biomarkers of one's relative distress.

We can categorize certain thoughts, people, sounds, feelings, etc into categories that either make us feel safe (SIM) or threatened (DIM) .

  • A DIM (danger in me) is anything you perceive to be dangerous to your body, well being or yourself as a person.

  • Conversely a SIM (safety in me) is anything that evokes a sense of health, happiness, comfort or confidence.

Step 2:

Give examples because DIMs and SIMs can really be anything:

  • a thought, belief or emotion you have

  • a feeling you have in your body (pain, stiffness, calm, balanced)

  • any sensation (anything you see, touch, smell, taste)

  • a relationship with someone (family, friends, medical practitioner)

  • a place (where you live, work or other)

  • past or present experiences

  • a "story" you've told yourself

A fairly frequent source of DIMs

Step 3:

Help them them start to identify their own

I have patients start by citing a few with me and then continuing on their own as homework.

If they struggle coming up with answers you might use the following:

  • For DIMs: What are the things in your life that cause you stress or worry? They can be related to your pain or other life things like your job, relationships, past events and feelings in your body.

  • For SIMs: What are the things in your life that make you feel healthy, strong, safe, confident and happy?

I encourage my patients to make two lists, one of DIMs and one of SIMs. Using a notebook is preferable so they can track change over time.

This step is also when is when I relate DIMs and SIMs to the Protectometer tool developed by the David Butler and Lorimer Moseley of the NOI group.

The Protectometer is your Danger-Safety meter. You might also call it a Stress meter. It goes up or down depending on the amount of DIMs/SIMs you have.

Here is a video demonstrating some examples of DIMs and SIMs on the Protectometer app.

Step 4:

Relate this concept back to their specific symptoms

Identifying these factors and quantifying whether you have more DIMs or SIMS can help one understand the onset, persistence or flareup of a stress output such as pain.

DIMs > SIMs = potential pain

Simple as a math equation BUT complex as each one of us.

Maybe your patient hates math. In that case, a visual of how symptoms can go up and down on the Protectometer helps.

Image from Explain Pain Supercharged

Step 5:

Slay the DIMs & Create more SIMs

Don’t stop at Step 1, 2, 3, or 4. You must help them get to and through Step 5.

What does it entail?


#slay those DIMs

This step is not "I just want you to think positive thoughts." In my experience that

doesn't work.

The most effective way to disarm threat is to figure out how to get them to feel safe.

We can do this by helping patients:

  • get rid of DIMs

  • convert DIMs into SIMs


  • enhance existing or develop new SIMs

Education, Movement, and Touch are effective ways to enhance a sense of safety (SIM).

Like it or not some DIMs are not going to disappear. That's ok.

It is having a greater sense of safety (than danger) in your body that is most important.

Balance doesn't necessarily mean equal

Step 6:


Who doesn't benefit from reminders?

Being able to refer back to the concept of DIMs and SIMs can provide a framework for understanding why symptoms persist or flare up. That in itself can decrease the threat.

Consistency in communication such as this provides a sense of safety.

This step is probably the most important because beliefs result from individual experience and perceptions. Information alone is not enough. Patients need repetitions and reinforcement.

The acronyms themselves can become a quick cue when you are conversing with your patient and you hear a DIM statement.

What I get really excited about is pointing out the SIM statements :)


Not only are DIMs/SIMs a way to start a conversation, they are also a manner with which to keep it going. This conversation may be one they have with you or with themselves.

Using DIMs and SIMS will empower patients to understand the multiple factors that are influencing their symptoms. With this improved awareness they'll be able to better connect the dots. The overriding goal is to enhance one's sense of safety but...

The first step is AWARENESS.

Photo credits:

Noi group

Kelly Sikkema from Unsplash


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