The role of anger and depression in recurrent headache

The Effectiveness of Mindful Hypnotherapy on Psychological Inflexibility, Pain Acceptance, Headache Disability and Intensity in Females with Chronic Migraine Headache: A Randomized Clinical Trial

This study was a randomized controlled design and examined the feasibility and effectiveness of mindful hypnotherapy on psychological inflexibility, pain acceptance, headache disability, and headache intensity in patients with chronic migraine headaches. The sample consisted of 38 females with chronic migraine who were randomly assigned to mindful hypnotherapy and medical treatment as usual groups. Psychological inflexibility pain scale (PIPS), chronic pain acceptance questionnaire-revised (CPAQ-R), headache disability inventory (HDI), diary scale for headache, and short-form McGill pain questionnaire 2 (SF-MPQ-2) were administered at baseline and post-treatment in both groups. The psychological inflexibility mean (SD) score was 81.00 (12.15) at baseline, which significantly decreased to 53.28 (17.06) after the intervention (p < 0.001). Additionally, the mean (SD) score of the pain acceptance was 46.44 (11.16), which significantly increased to 73.61 (15.65) in post-intervention (p < 0.001). Furthermore, the mean (SD) score of headache disability was 73.55 (19.48), which significantly decreased to 23.33 (19.88) in post-intervention (p < 0.001). Finally, headache intensity was 7.33 (0.98) and 5.78 (1.83), which significantly decreased to 2.77 (2.04), and 1.38 (1.48) after the intervention based on the Diary Scale for Headache and McGill Pain Questionnaire (SF-MPQ-2), respectively (p < 0.001). In conclusion, the results show that mindful hypnotherapy is a feasible and effective treatment for chronic migraine.

Salivary cortisol levels and appraisals of daily hassles across dimensions of the tripartite model of anxiety and depression in emerging adults

The objective of this study was to investigate how cortisol levels and appraisals of daily hassles differ across tripartite dimensions of depression and anxiety in emerging adults. Data collected from a sample of undergraduate students at a large Midwestern university was used to investigate these aims. This included salivary cortisol data collected over four days, scores on a measure of the tripartite model of anxiety and depression, and scores on a measure of daily hassles administered everyday for two weeks. Generalized estimating equations and multilevel modeling techniques were used to analyze data. Elevated cortisol levels during the awakening period and the evening period, lower total levels across the day, steeper diurnal slopes, and elevated levels of negative affect and physiological hyperarousal predicted experiences of daily hassles. Tripartite dimensions were unrelated to cortisol indices. The present study demonstrates the utility of modeling multiple cortisol indices and provides evidence of differential associations between physiological and phenomenological indices of stress.

The inhibition of verbally aggressive behaviour

We studied the inhibition of verbal aggression, defined as not displaying verbal aggression when one would want to. The approach we used was based on a situation–response questionnaire containing 15 anger provoking situations and three verbally aggressive responses. Two questions were asked for each combination of a situation and a response: one about wanting to react in a verbally aggressive way and one about actually displaying the reaction. This questionnaire was administered to 316 participants. Based on different theories about inhibition, several logistic mixed models were constructed and tested against each other. In the best fitting model, inhibition was conceptualized as a trait. Trait inhibition was negatively correlated with external measures of Anger Out and positively with Control of Anger Out. Copyright © 2004 John Wiley & Sons, Ltd.

Anger and impulsiveness in migraine patients with and without aura

Background and purpose: Migraine is a common primary headache disorder triggered by internal or external stimuli. Impulsitivity and anger are associated with many neurological and psychiatric disorders. The aim of this study was to investigate the anger and impulsivity in migraine patients with or without aura.Methods: A total of 55 patients aged between 18 and 55, who were diagnosed with episodic migraine (31 with aura and 24 without aura) and 40 healthy controls were enrolled in this prospective cross-sectional study.Migraine diagnosis and classification were based on criteria from the International Classification of Headache Disorders, 3rd edition (beta version). Multidimensional Anger Scale and Barratt Impulsivity Scale-11 were administered to the patient and control groups.Results:Migraine patients with aura, migraine patients without aura and control groups were compared, anger symptoms were significantly higher in migraine patients with aura (p < 0.001), but between these groups there was no significant difference in terms of impulsivity (p = 0.711).Conclusions: It was found that anger symptoms were more common in migraine patients with aura compared to migraine patients without aura and control group, but in impulsitivity there was no difference between groups.Further studies in future investigating the relation between migraine with aura and anger may pave the way for different and more specified treatment approach.

State and trait anger and its expression in cluster headache compared with migraine: a cross-sectional study

BACKGROUND

Anger is involved in the emotional experience of pain. Individuals with migraine are more likely to hold their anger-in than controls. However, only one study evaluated anger in cluster headache (CH). The objective is to compare anger between migraine and CH patients.

METHODS

One hundred thirty-five migraine and 108 CH patients completed the State Trait Anger Expression Inventory (STAXI-2), composed of 7 subscales. State Anger measures the intensity of the individual's angry feelings at the time of testing. Trait Anger evaluates general predisposition to become angry. Anger Expression Out and Anger Expression In measure the extent to which anger could be overtly expressed or suppressed. Anger Control Out and Anger Control In evaluate how individual try to control the outward or inward expression of anger. Anger Expression Index is a general index.

RESULTS

CH patients have higher median scores than migraine patients in State Anger (46 vs 44, p = 0.012). CH patients have lower scores in Anger Control Out (44 vs 50, p = 0.016). In subgroup analysis, CH patients during the cluster period have higher scores than chronic migraine patients in State Anger (47 vs 44, p = 0.035), while CH patients in headache-free period did not differ from migraine patients.

CONCLUSIONS

Migraine and CH patients differ in state anger, indicating that CH patients experienced higher intensity of anger during the time of testing. These data add new information about emotional regulation in headache patients and could support the hypothesis of different emotional and behavioral responses to pain in migraine and CH patients.

Spiritual Struggle Among Patients Seeking Treatment for Chronic Headaches: Anger and Protest Behaviors Toward God

This study examined anger and protest behaviors toward God among 80 US adults seeking treatment for chronic headaches (66 women, 14 men; 71 completed treatment). Measures were administered before and after an intensive 3-week outpatient treatment program. At both times, anger and protest toward God correlated with lower pain acceptance, more emotional distress, and greater perceived disability. However, when considered simultaneously, anger predicted sustained distress, whereas protest behaviors (e.g., complaining, questioning, arguing) predicted both reduced distress and an increased sense of meaning. These findings suggest the utility of distinguishing between anger toward God and behaviors suggesting assertiveness toward God.

Behavioural and Temperamental Characteristics of Children and Adolescents Suffering from Primary Headache

To examine indices of behavioural and emotional problems and temperamental traits in clinically referred children and adolescents suffering from tension headache or migraine. Headache in childhood and adolescence (<18 years) has been associated with the presence of behavioural and emotional difficulties, but limited data are available on the relationship between these problems and different types of headache. Clinically referred children and adolescents ( N = 114), 6–16 years of age, suffering from primary headache according to the diagnostic criteria of the International Headache Society, 47 with tension-type headache (TH) and 67 with migraine (M), and 36 normal controls without headache (NC) were assessed using the Parent Child Behaviour Checklist (CBCL), Children's Depression Inventory (CDI), Multidimensional Anxiety Scale for Children (MASC), Conner's Parent Rating Scale (CPRS), and Emotionality–Activity–Sociability–Shyness Scale (EAS). Psychological and personality self-rating assessments were obtained also on the children's parents and siblings. Although most headache patients had scores within the normative non-pathological range, both TH and M patients had higher CBCL total, internalizing, and externalizing scores than NC ( P < 0.001), and TH patients had higher scores than M patients. TH and M had higher CDI and MASC scores than NC ( P < 0.05), with no difference between the headache groups. TH patients had higher Emotionality and Shyness scores, and lower Sociability scores than M patients. Clinically referred children and adolescents with TH and M had higher scores of behavioural and emotional symptoms, both of internalizing and externalizing type, than normal peers. The TH group had greater psychological and temperamental difficulties than the M group.

Screening for depression and anxiety disorder in children with headache

Purpose

The purpose of this study was to investigate the importance of initial screening tests for depression and anxiety disorders in children with headache. In addition, this study evaluated whether the Children's Depression Inventory (CDI) and Revised Children's Manifest Anxiety Scale (RCMAS) are suitable for screening symptoms of depression and anxiety.

Methods

A retrospective chart review was conducted of 720 children aged 7-17 years who had visited a pediatric neurology clinic for headaches and were referred to a pediatric psychiatric clinic for psychiatric symptoms from January 2010 to December 2011. All patients completed the CDI and RCMAS. Among them, charts of patients with clinically significant total scores (cutoff>15) for psychiatric symptoms, as defined by the CDI and RCMAS scoring scales, were reviewed.

Results

Nineteen patients had headaches and clinically significant total scores for psychiatric symptoms. The mean age at headache diagnosis was 11.7 years, and 57% were male. Mean duration of headache was 11.5 months. Two point eight percent of the patients were diagnosed with psychiatric disorders including major depression (1.7%), generalized anxiety disorder (1.1%), and bipolar disorder (0.1%). Four patients (0.6%) were diagnosed with attention deficit/hyperactivity disorder (ADHD). Total mean CDI and RCMAS scores of patients referred to the psychiatric clinic were 18.8 and 22.2, respectively. There was no correlation between CDI or RCMAS total scores and headache frequency, duration, or severity.

Conclusion

We recommend that all patients with headache should be screened for depression and anxiety by CDI and RCMAS scores.

Psychosocial factors and central sensitivity syndromes

Central sensitivity syndromes (CSSs) represent a heterogeneous group of disorders (e.g., fibromyalgia [FM], irritable bowel syndrome [IBS], chronic headache, temporomandibular disorders [TMDs], pelvic pain syndromes) that share many common symptoms, with persistent pain being the most prominent feature. Although the etiology and pathophysiology of CSSs are currently incompletely understood, central sensitization has emerged as one of the significant mechanisms. Given that there are currently no known cures for CSSs, people living with these disorders must learn to cope with and manage their symptoms throughout their lives. Medical interventions alone have not proven to be sufficient for helping people with CSSs manage their symptoms. A biopsychosocial perspective that considers the ways that biological, psychological, and social factors work independently and jointly to affect a person's experience is the most effective conceptualization and guide for effective treatment. In this article, we discuss several psychological and social features that may influence the experience of a person with CSS and their symptom management, regardless of their specific diagnosis. We highlight the longitudinal aspect of adjustment to illness, the distinction between psychosocial factors as causes of symptoms versus modifiers and perpetuators of symptoms, dispel the notion that all patients with the same diagnosis are a homogeneous group (the "patient-uniformity myth"), and acknowledge the importance of environmental and situational context on symptom management for individuals with any CSS.

Effects of anger awareness and expression training versus relaxation training on headaches: a randomized trial

BACKGROUND AND PURPOSE

Stress contributes to headaches, and effective interventions for headaches routinely include relaxation training (RT) to directly reduce negative emotions and arousal. Yet, suppressing negative emotions, particularly anger, appears to augment pain, and experimental studies suggest that expressing anger may reduce pain. Therefore, we developed and tested anger awareness and expression training (AAET) on people with headaches.

METHODS

Young adults with headaches (N = 147) were randomized to AAET, RT, or a wait-list control. We assessed affect during sessions, and process and outcome variables at baseline and 4 weeks after treatment.

RESULTS

On process measures, both interventions increased self-efficacy to manage headaches, but only AAET reduced alexithymia and increased emotional processing and assertiveness. Yet, both interventions were equally effective at improving headache outcomes relative to controls.

CONCLUSIONS

Enhancing anger awareness and expression may improve chronic headaches, although not more than RT. Researchers should study which patients are most likely to benefit from an emotional expression or emotional reduction approach to chronic pain.

Psychological issues in the evaluation and treatment of tension-type headache

Tension-type headache is the most common headache disorder, affecting approximately 40 % of Americans within a one-year span. Although the most common form, episodic tension-type headache, is rarely impairing, more frequent tension-type headache can occur with significant disability and psychological comorbidity. Appreciating the psychological impact, assessing the associated biopsychosocial issues, and understanding patients' coping styles are important in forming an appropriate treatment plan and maximizing treatment outcomes. A range of psychological therapies including relaxation training, cognitive behavioral therapy, biofeedback and mindfulness have demonstrated utility in treating chronic pain conditions and reducing the associated disability. This may be particularly applicable to special populations, including pediatric patients, pregnant patients and geriatric. Psychological assessment and treatment may be done conjointly with medication management and expands treatment options. There is great need to continue researching the effects of psychological treatments, standardizing interventions and making them available to the wider population.

Clinical features, anger management and anxiety: a possible correlation in migraine children

BACKGROUND

Psychological factors can increase severity and intensity of headaches. While great attention has been placed on the presence of anxiety and/or depression as a correlate to a high frequency of migraine attacks, very few studies have analyzed the management of frustration in children with headache. Aim of this study was to analyze the possible correlation between pediatric migraine severity (frequency and intensity of attacks) and the psychological profile, with particular attention to the anger management style.

METHODS

We studied 62 migraineurs (mean age 11.2 ± 2.1 years; 29 M and 33 F). Patients were divided into four groups according to the attack frequency (low, intermediate, high frequency, and chronic migraine). Pain intensity was rated on a 3-levels graduate scale (mild, moderate and severe pain). Psychological profile was assessed by Picture Frustration Study test for anger management and SAFA-A scale for anxiety.

RESULTS

We found a relationship between IA/OD index (tendency to inhibit anger expression) and both attack frequency (r = 0.328, p = 0.041) and intensity (r = 0.413, p = 0.010). When we analyzed the relationship between anxiety and the headache features, a negative and significant correlation emerged between separation anxiety (SAFA-A Se) and the frequency of attacks (r = -0.409, p = 0.006). In our patients, the tendency to express and emphasize the presence of the frustrating obstacle (EA/OD index) showed a positive correlation with anxiety level (“Total anxiety” scale: r = 0.345; p = 0.033).

CONCLUSIONS

Our results suggest that children suffering from severe migraine tend to inhibit their angry feelings. On the contrary, children with low migraine attack frequency express their anger and suffer from separation anxiety.

Psychological assessment in children and adolescents with Benign Paroxysmal Vertigo

Migraine in childhood and adolescence has been associated with the presence of behavioural and emotional difficulties, but only few data are available with respect to unusual types of headache syndromes such as Benign Paroxysmal Vertigo of Childhood (BPVC). Aim of the present study was to evaluate the behavioural and emotional profiles of clinically referred children and adolescents suffering from BPVC and migraine, as compared to normal controls. According to the revised International Classification of Headache Disorders (ICHD-2) the BPVC belongs to the category of "primary headache", as a migraine equivalent, in a subset that is called "periodic syndromes of childhood". A total of 60 clinically referred children and adolescents (4-15 years) 21 suffering from BPVC and 20 from migraine, according to the diagnostic criteria of the ICHD-2, and 19 normal control (NC) were recruited in this study. Psychological assessment were performed using the Child Behaviour Checklist (CBCL), the Children's Depression Inventory (CDI) and the Multidimensional Anxiety Scale for Children (MASC). Although most of the patients suffering from headache had scores within the normative non-pathological range, both BPVC and migraine patients had significantly higher CBCL total, internalizing, and externalizing scores, as compared to NC. Furthermore, both BPVC and migraine groups displayed significantly higher CDI and MASC scores than NC group. No differences were found between the two types of headache. In conclusion, clinically referred children and adolescents with BPVC and migraine showed higher indices of behavioural and emotional symptoms, both internalizing and externalizing, as compared to normal peers.

Temperament traits of children with episodic tension-type headaches

BACKGROUND

The association between headache and stress is discussed. A powerful source of stress and the ways of relation between stress and headache can differed. The individual vulnerability to stress may be related to one's temperament.

OBJECTIVE

The purpose of the present study was to evaluate the role of temperament traits in children with episodic tension-type headaches (ETTH).

METHODS

We examined 120 children, 6-16 years of age, in the Department of Developmental Neurology of the Medical University of Gdansk. All children were diagnosed with ETTH. The control group consisted of 60 age-matched children without headaches. The following instruments of assessment were used: survey-interview, EAS Temperament Survey (Buss and Plomin), and Stress Response Scale (Chandler). The results were evaluated using statistical analysis.

RESULTS

Our results showed differences in temperament traits in children with ETTH compared to children without headaches. The former demonstrated greater temperament instability, i.e., higher emotionality, an intensified level of fear, a lower level of vigour, and a higher level of shyness compared to the control group.

CONCLUSION

Children with ETTH have some different traits than children without headache.

Pain-related effects of trait anger expression: neural substrates and the role of endogenous opioid mechanisms

Literature is reviewed indicating that greater tendency to manage anger via direct verbal or physical expression (trait anger-out) is associated with increased acute and chronic pain responsiveness. Neuroimaging data are overviewed supporting overlapping neural circuits underlying regulation of both pain and anger, consisting of brain regions including the rostral anterior cingulate cortex, orbitofrontal cortex, anterior insula, amygdala, and periaqueductal gray. These circuits provide a potential neural basis for observed positive associations between anger-out and pain responsiveness. The role of endogenous opioids in modulating activity in these interlinked brain regions is explored, and implications for understanding pain-related effects of anger-out are described. An opioid dysfunction hypothesis is presented in which inadequate endogenous opioid inhibitory activity in these brain regions contributes to links between trait anger-out and pain. A series of studies is presented that supports the opioid dysfunction hypothesis, further suggesting that gender and genetic factors may moderate these effects. Finally, possible implications of interactions between trait anger-out and state behavioral anger expression on endogenous opioid analgesic activity are described.

Chronic tension-type headache in adolescents. Clinical and psychological characteristics analyzed through self- and parent-report questionnaires

OBJECTIVES

To analyze the relation between the symptoms reported by adolescents with chronic tension-type headache (CTTH) and their perception of their emotional and behavioral functioning.

METHODS

Two groups of adolescents (clinical group, n = 48; control group, n = 135) and their parents (clinical group, n = 42; control group, n = 128) were studied, respectively, with the Youth Self-Report Questionnaire and the Child Behavior Checklist. Moreover, a secondary analysis was performed, identifying another subgroup of adolescents who reported having headaches.

RESULTS

The clinical group of adolescents obtained higher scores than the control group in Internalizing Syndrome; Aggressive Behavior for Externalizing Syndrome; Social, Thought, and Attention Problems; and in all Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)-oriented scales (except conduct problems). Differences between the two groups of parents were found in all the scales. The controls reporting headaches obtained interesting intermediate scores.

CONCLUSIONS

Adolescents with CTTH show greater emotional and behavioral problems than their healthy peers. Consequently, clinical approaches for proper diagnosis and treatment need to adopt a multidisciplinary prospective.

Trait anger management style moderates effects of actual ("state") anger regulation on symptom-specific reactivity and recovery among chronic low back pain patients

OBJECTIVES

We examined whether "state" anger regulation-inhibition or expression-among chronic low back pain (CLBP) patients would affect lower paraspinal (LP) muscle tension following anger-induction, and whether these effects were moderated by trait anger management style.

METHOD

Eighty-four CLBP patients underwent harassment, then they regulated anger under one of two conditions: half expressed anger by telling stories about people depicted in pictures, whereas half inhibited anger by only describing objects appearing in the same pictures. They completed the anger-out and anger-in subscales (AOS; AIS) of the anger expression inventory.

RESULTS

General Linear Model procedures were used to test anger regulation condition by AOS/AIS by period interactions for physiological indexes. Significant three-way interactions were found such that: a) high trait anger-out patients in the inhibition condition appeared to show the greatest LP reactivity during the inhibition period followed by the slowest recovery; b) high trait anger-out patients in the expression condition appeared to show the greatest systolic blood pressure (SBP) reactivity during the expression period followed by rapid recovery.

CONCLUSIONS

Results implicate LP muscle tension as a potential physiological mechanism that links the actual inhibition of anger following provocation to chronic pain severity among CLBP patients. Results also highlight the importance of mismatch situations for patients who typically regulate anger by expressing it. These CLBP patients may be at particular risk for elevated pain severity if circumstances at work or home regularly dictate that they should inhibit anger expression.

A factor analytic investigation of the Tripartite model of affect in a clinical sample of young Australians

BACKGROUND

The Mood and Anxiety Symptom Questionnaire (MASQ) was designed to specifically measure the Tripartite model of affect and is proposed to offer a delineation between the core components of anxiety and depression. Factor analytic data from adult clinical samples has shown mixed results; however no studies employing confirmatory factor analysis (CFA) have supported the predicted structure of distinct Depression, Anxiety and General Distress factors. The Tripartite model has not been validated in a clinical sample of older adolescents and young adults. The aim of the present study was to examine the validity of the Tripartite model using scale-level data from the MASQ and correlational and confirmatory factor analysis techniques.

METHODS

137 young people (M = 17.78, SD = 2.63) referred to a specialist mental health service for adolescents and young adults completed the MASQ and diagnostic interview.

RESULTS

All MASQ scales were highly inter-correlated, with the lowest correlation between the depression- and anxiety-specific scales (r = .59). This pattern of correlations was observed for all participants rating for an Axis-I disorder but not for participants without a current disorder (r = .18). Confirmatory factor analyses were conducted to evaluate the model fit of a number of solutions. The predicted Tripartite structure was not supported. A 2-factor model demonstrated superior model fit and parsimony compared to 1- or 3-factor models. These broad factors represented Depression and Anxiety and were highly correlated (r = .88).

CONCLUSION

The present data lend support to the notion that the Tripartite model does not adequately explain the relationship between anxiety and depression in all clinical populations. Indeed, in the present study this model was found to be inappropriate for a help-seeking community sample of older adolescents and young adults.

Direct diagnosis and management of emotional factors in chronic headache patients

Somatization, anxiety, depression and personality disorders are common features of many patients with chronic headaches. Intensive short-term dynamic psychotherapy (ISTDP) is a brief therapy method developed specifically to treat patients with this cluster of somatic problems, symptoms and maladaptive behaviours through focusing on how the patient handles emotional experiences. It also contains a direct method of assessing the somatic discharge pathways of both emotions and anxiety, thus allowing direct observation of somatization in the case of many chronic headache sufferers. In this review, we summarize the extant literature on emotional factors in headache, review the evidence for short-term dynamic therapies in somatic problems and describe the assessment and treatment method of ISTDP we use routinely with chronic headache sufferers.

Anger inhibition and pain: conceptualizations, evidence and new directions

Anger and how anger is regulated appear to affect acute and chronic pain intensity. The inhibition of anger (anger-in), in particular, has received much attention, and it is widely believed that suppressing or inhibiting the verbal or physical expression of anger is related to increased pain severity. We examine theoretical accounts for expecting that anger inhibition should affect pain, and review evidence for this claim. We suggest that the evidence for a link between trait anger-in (the self-reported tendency to inhibit anger expression when angry) and acute and chronic pain severity is quite limited owing to a number of factors including a inadequate definition of trait anger-in embodied in the popular anger-in subscale of Spielberger's Anger Expression Inventory, and a strong overlap between trait anger-in scores and measures of general negative affect (NA). We argue that in order to determine whether something unique to the process of anger inhibition exerts direct effects on subsequent pain intensity, new conceptualizations and approaches are needed that go beyond self-report assessments of trait anger-in. We present one model of anger inhibition and pain that adopts elements of Wegner's ironic process theory of thought suppression. Findings from this emerging research paradigm indicate that state anger suppression (suppression manipulated in the laboratory) may indeed affect sensitivity to subsequent painful stimuli, and we outline potentially productive avenues of future inquiry that build on this model. We conclude that although studies employing correlational designs and self-reports of trait anger-in have not upheld the claim that anger inhibition affects pain severity, evidence from studies using new models suggests that actually inhibiting anger expression during a provocative event may increase perceived pain at a later time.

The passing dilemma in socially invisible diseases: Narratives on chronic headache

This contribution concerns the experience of chronic diseases and how it disrupts the trajectory of a person's biography, undermining his/her identity, self-reliance and social relationships. The study focuses particular attention on those diseases which have not yet been fully acknowledged and can, therefore, be considered a socially invisible disease: chronic headache is one of these. Thirty-one life stories were collected from patients attending a specialized headache centre in Northern Italy, and selected in order to include all common varieties of chronic headache. Following the principles of grounded theory, interviews began by adopting a minimal theoretical framework which consisted of asking people how they became aware of the objective (disease), subjective (illness) and social (sickness) aspects of their condition. The analysis highlighted particular points in the patients' life trajectories: first, the biographical disruption that takes place because of the disease; second, how people succeed or fail in identity negotiation, which is vital for developing an acceptable social representation of the disease. Results show that patient's choices follow a vicious circle, where a partial social representation of the disease is produced. People who suffer from chronic headache face a dilemma in social relationships: should they conceal their disease, or make it evident? If they conceal, any possible social representation of the disease is denied, which could lead to carrying the burden of the disease alone, with no social support. On the other hand, making chronic headache visible could result in stigma.

Anger, depression and personality dimensions in patients with migraine without aura

BACKGROUND

Migraine without aura causes acute and chronic pain and partially compromises patients' social functioning and work performance. Over the past years, psychiatric comorbidities were frequently observed in these patients, together with coping difficulties and typical personality traits. The aim of this study was to identify whether migraine patients and controls share distinctive personality traits.

METHODS

105 consecutive patients suffering from migraine without aura referred to the Headache Center of Turin University were enrolled in the study and compared to a control group of 79 healthy subjects. Patients and controls completed several psychometric questionnaires, including the Temperament and Character Inventory, the Beck Depression Inventory and the State-Trait Anger Expression Inventory.

RESULTS

Patients suffering from migraine show more depressive symptoms, difficult anger management with a tendency to hypercontrol, and a distinctive personality profile with high harm avoidance, high persistence and low self-directedness. When a logistic regression was performed, the only significant predictors of migraine were temperament variables.

CONCLUSIONS

The results suggest that the personality traits and psychosomatic mechanisms of migraine patients may make them vulnerable to stress and less skilled in coping with pain. These traits correlate with dysregulated neurotransmitter systems which may also be part of the psychobiological components of personality, depressive disorders and migraine itself.

Psychological risk factors in headache

Headache is a chronic disease that occurs with varying frequency and results in varying levels of disability. To date, the majority of research and clinical focus has been on the role of biological factors in headache and headache-related disability. However, reliance on a purely biomedical model of headache does not account for all aspects of headache and associated disability. Using a biopsychosocial framework, the current manuscript expands the view of what factors influence headache by considering the role psychological (i.e., cognitive and affective) factors have in the development, course, and consequences of headache. The manuscript initially reviews evidence showing that neural circuits responsible for cognitive-affective phenomena are highly interconnected with the circuitry responsible for headache pain. The manuscript then reviews the influence cognitions (locus of control and self-efficacy) and negative affect (depression, anxiety, and anger) have on the development of headache attacks, perception of headache pain, adherence to prescribed treatment, headache treatment outcome, and headache-related disability. The manuscript concludes with a discussion of the clinical implications of considering psychological factors when treating headache.

Anger management style and hostility among patients with chronic pain: effects on symptom-specific physiological reactivity during anger- and sadness-recall interviews

OBJECTIVES

We examined whether anger-in, anger-out, and hostility predicted symptom-specific muscle tension reactivity during anger induction (but not sadness induction) among patients with chronic low back pain (CLBP). For patients with CLBP, relevant muscles are the lower paraspinals (LPs). Anger-in x hostility and anger-out x hostility interactions were tested to determine whether particularly reactive groups of patients could be identified with a multivariable profile approach.

METHODS

Ninety-four patients with CLBP underwent anger recall (ARI) and sadness recall (SRI) interviews, whereas LP and trapezius electromyography and systolic blood pressure, diastolic blood pressure, and heart rate were recorded. They completed anger-in, anger-out, hostility, and trait anger measures.

RESULTS

Hierarchical regressions were used to test anger-in x hostility and anger-out x hostility interactions for physiological changes during the ARI and SRI. A significant anger-in x hostility interaction was found for LP change during the ARI (but not SRI) such that high anger-in/high hostility patients evinced the greatest reactivity. Effects for trapezius reactivity were nonsignificant. Significant anger-in x hostility interactions were also found for systolic blood pressure and diastolic blood pressure changes during the ARI such that high anger-in/low hostility patients showed the smallest changes. The anger-out x hostility interaction for diastolic blood pressure change during ARI was also significant such that high anger-out/low hostility patients showed the smallest changes. All effects remained significant with trait anger controlled.

CONCLUSIONS

A multivariable profile approach may help identify especially vulnerable patient groups. Patients with CLBP who tend to suppress anger and are cynically hostile may be more likely to experience high levels of muscle tension near the site of pain and injury during anger, but not during sadness, than other groups.

Anger expression and pain: an overview of findings and possible mechanisms

A tendency to manage anger via direct expression (anger-out) is increasingly recognized as influencing responses to pain. Elevated trait anger-out is associated with increased responsiveness to acute experimental and clinical pain stimuli, and is generally related to elevated chronic pain intensity in individuals with diverse pain conditions. Possible mechanisms for these links are explored, including negative affect, psychodynamics, central adipose tissue, symptom specific muscle reactivity, endogenous opioid dysfunction, and genetics. The opioid dysfunction hypothesis has some experimental support, and simultaneously can account for anger-out's effects on both acute and chronic pain. Factors which may moderate the anger-out/pain link are described, including narcotic use, gender, and genetic polymorphisms. Pain exacerbating effects of trait anger-out are contrasted with the apparent pain inhibitory effects of behavioral anger expression exhibited in anger-provoking contexts. Conceptual issues related to the state versus trait effects of expressive anger regulation are discussed.

Disability is the major determinant of the severity of depressive symptoms in primary headaches but not in low back pain

Pain syndromes are often associated with depression. In a prospective study we analysed if determinants of depression differ among patients with different primary headaches and between headaches and non-headache pain. During a 2-year period between 1 February 2002 and 31 January 2004, 635 subjects (migraine n = 231; tension-type headache n = 176; cluster headache n = 11; patients with low back pain n = 103; and healthy subjects n = 114) seen by two neurologists filled in a questionnaire on pain characteristics, the MIDAS questionnaire and the Beck Depression Inventory. A multivariate general regression model was used to identify independent predictors of the severity of depressive symptoms. Pain was most frequent in chronic tension-type headache and most intense in the cluster subgroup (P < 0.001, Kruskal-Wallis ANOVA). In univariate tests gender, age, pain frequency, pain intensity and disability were all significantly associated with the severity of depressive symptoms. In the multivariate model disability was the most important independent determinant of the severity of depressive symptoms in the pooled headache group as well as in the migraine and tension-type headache subgroups. In contrast to patients with headache, pain frequency and pain intensity were the significant independent predictors of the severity of depressive symptoms in patients with low back pain. In a multivariate model, after controlling for other factors, determinants of the severity of depressive symptoms were different in headache and non-headache pain subjects, suggesting a different mechanism for developing depression in primary headaches and in other pain syndromes.

The relationship between anger and pain

Anger is defined with reference to a cognitive-motivational perspective. This forms the basis for identifying the variety of reasons why pain sufferers are angry and the many ways in which they react when angry. Statistics are provided for the comorbidity of anger in chronic pain and headache. Going beyond such statistics, five dynamic interactions between anger and pain are emphasized and empirical evidence is provided for each of these interactions.

Toward an understanding of the determinants of anger

Research bearing on several popular conceptions of the major determinants of anger arousal indicates that the particular appraisals often identified as causes of anger frequently only serve to affect the intensity of the anger that is generated. Research into effects of physical pain or other physically unpleasant conditions or involving social stresses suggests that decidedly aversive conditions are a major spur to anger. Experiments are also reviewed showing that anger-related muscular movements can also lead to anger-related feelings, memories, cognitions, and autonomic responses. Alternative explanations for the findings are discussed. The authors urge emotion theorists to widen their methodology and analyses so that they give careful, detailed attention to the many different factors that can influence anger.

Differences in anger expression between individuals with and without headache after controlling for depression and anxiety

OBJECTIVE

To evaluate whether anger and anger expression are different between persons with and without headache after controlling for depression and anxiety.

BACKGROUND

Persons with headache may experience more problems with anger and its expression when compared with persons without headache. It is important to establish whether differences exist for persons with and without headache on trait anger and anger expression independent of depression and anxiety. To date, however, this issue has received little attention in the empirical literature. The current study measured trait anger, anger-in, hostility, anxiety, and depression among persons with and without headache, and evaluated whether trait anger and anger-in differentiated groups independent of depression and anxiety.

METHODS

Participants were 422 adults recruited from a larger study within a university setting. Of those, 171 suffered from headache (mean age, 21 years; 81% were female; 69% were white; mean years with pain, 7.53). Another 251 sex-matched individuals (mean age, 21 years; 81% female; 62% white) met criteria for the headache-free group. Participants provided information regarding their headache characteristics and were administered affective trait measures (Trait version of the State-Trait Anxiety Inventory, Brief Symptom Inventory-Depression), trait anger measures (Trait Anger Scale, Cook-Medley Hostility Scale), and a measure of the extent to which individuals hold their anger in.

RESULTS

Multivariate analysis of variance revealed significant differences between the 2 groups (Wilks lambda =.86, P <.001, eta2 =.14). Step-down analysis revealed that even after controlling for all other variables, those in the headache group had higher levels of anger-in (P <.001, eta2 =.08; mean, 18.98 versus 15.68). Trait anger and hostility did not differ between groups after controlling for depression and anxiety. Logistic regression revealed that anger-in contributed most to predicting headache status (P <.001; partial r =.23).

CONCLUSIONS

The current findings indicate that persons with headache hold their anger in more than those without headache even after controlling for levels of trait anger, depression, and anxiety. However, after controlling for depression and anxiety, individuals no longer differed on trait anger. Also, anger-in was the strongest predictor of headache. The current findings suggest that holding anger in is more common among headache sufferers. Given recent findings regarding the negative effect of holding anger in among persons with pain conditions, this may be an important factor to evaluate when considering psychological/emotional factors affecting headache.