POINT OF VIEW:
The Psychologist in a Headache Clinic Richard A. Sternbach, Ph.D., and Donald J. Dalessio, M.D. Scripps Clinic Medical Group, Inc. (Drs Sternbach and Dalessio) Reprint requests to Scripps Clinic Medical Group Inc., 476 Prospect St., La Jolla, CA 92037 (Dr Sternbach) Accepted for Publication: 11/22/76 (Headache 17:9-11, 1977) BY COMBINING results from psychologic tests and clinical interviews the psychologist contributes to the management of headache patients. He can also be responsible for biofeedback training which is useful for the treatment of muscle contraction headaches and for some forms of vascular headaches. In evaluating the success of treatment, the psychologist's training in experimental design and statistical analyses can make an important contribution, TESTS Psychologic tests complement the mental status information obtained in clinical interviews. No psychologic tests, however, can determine whether a patient's symptoms are psychogenic or somatogenic. It is not possible to distinguish effects of chronic somatogenic pain statesfrom conversion reaction or psychophysiologic pain. Such distinctions must be based upon history and physcial examination, with some assistance from psychologic findings. The psychologic effects of chronic pain are virtually indistinguishable from neurotic reactions in which pain is a symptom. Just as acute pain and anxiety share common features (autonomic reactions), so chronic pain and depression have similar patterns (vegetative changes). Attempts have been made to use psychologic tests to distinguish psychogenic from somatogenic, or functional from organic disorders. The attempts have failed and a headache scale on the MMPI did not prove helpful. Psychologic tests give a psychologic diagnosis with an estimate of the severity of the disturbance. The MMPI is a widely used psychologic test; it can give psychologic diagnosis, and has a number of other scales of interest also. Among these are a scale of addiction-proneness, and an ego-strength scale which predicts resistance to emotional disorder and the likelihood of favorable response to treatment. The MMPI can indicate whether an affective disorder or thought disturbance exists, and the need for psychotropic medications. Thus the emphasis is less on the importance of psychologic factors in the etiology of headache, and more on psychologic findings in need of treatment, regardless of causation. A number of brief tests supplement the MMPI and provide information on chronic invalidism, resentment towards doctors, adaptive or maladaptive illness behavior, if health concern reflects mere symptom preoccupation, disease phobia, or conviction of serious illness. The Health Index, a 50-item questionnaire with scales of chronic invalidism, manifest depression, pain preoccupation, and problems with health professionals. We now use an expanded Illness Behavior Questionnaire, a single 80-item Health Index with eleven scales permitting clinical description of the patient. This information can provide a profile of the psychologic state of the patient. It can suggest the need for psychiatric treatment, whether it is likely to be accepted by the patient, and the probability of success of any treatment. INTERVIEW The clinical psychologic interview focuses on the impact of the headache on daily activities. Generally, headaches are less disabling than other
syndromes encountered in a pain clinic, but there are exceptions, and of importance is the degree to which the headaches are intermittent or constant. Emphasis on the disruptive effect of the headaches give the psychologist insight whether and to what extent interpersonal relationships are affected at home and/or work. This identifies sources of stress within these relationships, and indirectly suggests whether there may be conflicts within the patient. Much is determined by how the patient answers and by the content of the answers. Possible games which may reinforce headache symptoms, and the degree to which the patient may be open to psychologic interpretation are assessed. Thus psychologic tests give the nature and degree of psychopathology, and the clinical interview the specific content of the stresses and conflicts. Whether the headaches are psychologic or somatic in origin is less important than whether there are significant psychologic or physical findings. Abnormalities in each area require treatment intervention in parallel, ignoring causation. The issue of which came first, the psychologic or physical factors, is of theoretical interest but of little practical consequence. The combined psychologic findings from test results and interview lead to treatment. Treatment includes psychotropic agents, psychotherapy, situational adjustments, or behavioral therapies. Sometimes brief psychotherapy occurs, in the form of crisis intervention, during the diagnostic interview. An example of psychologic evaluation, a composite of several actual case reports is given below. PSYCHOLOGIC EVALUATION A short, plump, very pleasant woman of 56, in no distress during our interview, eventually became tearful in describing the desperateness of her situation. She has had mixed muscle contraction and vascular headaches for some time. The muscle contraction headaches appear to be associated with degenerative disease and spurring of the cervical vertebrae and can also trigger the vascular headaches. A number of treatments have provided some relief. Recently, however, she has had an increased severity, frequency and duration of her head pains. She has been severely depressed, and was finally persuaded by her family physician to see a psychiatrist. For six sessions she knew nothing of what happened to her because the psychiatrist gave her sodium pentothal and several hours later a nurse would awaken her. At the end of the sixth session she requested some information and was told she needed electroshock therapy because she was not cooperative. She did not pursue this further. The patient also had biofeedback training for muscle relaxation and she practices this technique. She feels that it does help and she is not so depressed as she was formerly. However, biofeedback training has not helped her vascular headaches very much. Her hands and feet become very cold when she is having severe headaches and she frequently has body chills. She had such severe circulatory problems with her feet that she went to see a dermatologist because of the discoloration. He told her that the blotchiness was a vascular rather than dermatologic problem. The patient is not now taking any antidepressant medications. She was on desipramine for about a year and one-half and did much better; however, she gained weight and is still trying to lose the weight. She says she is still "depressed" because she really enjoys keeping up her home and garden, having the grandchildren over, etc., but the headaches interfere with this activity. Psychologic tests: The Health Index showed moderate chronic invalidism, slight manifest depression, moderate pain preoccupation, and slight disappointment with doctors for not having helped the pain. The overall pattern was one of moderate impact of pain on daily activities and some psychologic reaction to this. On the Whiteley Index of Hypochondriasis, she scored only slightly lower than average for psychiatric hypochondfiacal patients. Her serious health concern consists of severe symptoms preoccupation, but there is also some disease phobia and conviction of the presence of serious illness. The MMPl was taken defensively, the patient attempting to portray herself as conventional, virtuous, and emotionally stable. She has a strong need to see herself (and be seen by others) without even minor faults which most of us admit to. The clinical profile shows a striking chronic pain syndrome with marked focus on symptom preoccupation and excessive use of denial and repression.
This keeps her depressive reaction at borderline clinical significance, and is accompanied by a marginally important anxiety. A tendency to slight agitation, although not clinically significant, is also present. The tests show her very feminine, overly passive, who permits imposition and may even invite it, but then responds with resentment towards those who impose upon her. An introverted person, she cannot express her anger or assert herself, and this may contribute to her depressive reaction. The tests show her not addiction-prone, but she has little ego strength, and she may not respond to mere symptom alleviation without efforts directed at her psychologic state also. Impression: 1) Mixed muscle contraction and vascular headaches. 2) No psychiatric diagnosis- chronic pain syndrome with borderline anxious depressive reaction. Discussion and Recommendations: The patient is to return to biofeedback for training in temperature control. I believe this skill if practiced may reduce the frequency and severity of the vascular component of her head pain. Because her muscle contraction headaches may be triggered by spasms associated with cervical osteoarthritis, I have instructed her in the use of a transcutaneous electrical neurostimulator, placing a pair of electrodes high on either side of the cervical spine. She will be telephoning in one week to report on her progress. I do not believe that the patient is significantly disturbed. Although she calls her discouragement "depression", her anxious depressive reaction is not clinically significant. Therefore, psychotropic drugs are not indicated at present. TREATMENT MODALITIES Traditional psychotherapy, such as psychoanalysis and psychodynamic psychotherapy, have not been very successful for headache treatment. These therapies require some verbal ability and psychologic mindedness, are very expensive, slow, and limited to a small number of patients. What is needed is an efficient system for modifying the pathophysiologic processes in headache. Biofeedback provides such a system. Its usefulness is supported by animal and human experimental studies and in clinical settings. However, controlled follow-up studies are few, but suggest that motivated patients who continue to practice maintain therapeutic gains at an approximate 50% success rate. Part of the difficulty in biofeedback treatment of headache is choosing the underlying physiologic variable to "feed back" to the patient. It was thought that frontalis muscle relaxation was useful in all muscle contraction headache. Now it appears, however, that cervical paraspinal muscles are more appropriate in some patients. Similarly, hand-warming techniques do not apply to all vascular headaches. Peripheral vascular changes do not occur in all vascular headaches, and another variable must be found for these forms of headache. In addition to biofeedback, other techniques may be of value. Aversion conditioning may be helpful in blephorospasm and bruxism and transcutaneous electrical neurostimulation may help in degenerative disc disease of the cervical spine. RESEARCH In addition to giving diagnostic information and behavioral treatment, the psychologist can evaluate ongoing treatment and design experimental research. His training in experimental design and statistical analysis may be useful for controlled outcome studies of a treatment procedure, or to clinically test the effectiveness of a drug without sacrificing the methodology of a proper experiment. Research in a clinical setting is difficult but this challenge and the hard-nosed skepticism which it entails, frequently improves patient care.
The Psychologist in a Headache Clinic Richard A. Sternbach, Ph.D., and Donald J. Dalessio, M.D. Scripps Clinic Medical Group, Inc. (Drs Sternbach and Dalessio) Reprint requests to Scripps Clinic Medical Group Inc., 476 Prospect St., La Jolla, CA 92037 (Dr Sternbach) Accepted for Publication: 11/22/76 (Headache 17:9-11, 1977) BY COMBINING results from psychologic tests and clinical interviews the psychologist contributes to the management of headache patients. He can also be responsible for biofeedback training which is useful for the treatment of muscle contraction headaches and for some forms of vascular headaches. In evaluating the success of treatment, the psychologist's training in experimental design and statistical analyses can make an important contribution, TESTS Psychologic tests complement the mental status information obtained in clinical interviews. No psychologic tests, however, can determine whether a patient's symptoms are psychogenic or somatogenic. It is not possible to distinguish effects of chronic somatogenic pain statesfrom conversion reaction or psychophysiologic pain. Such distinctions must be based upon history and physcial examination, with some assistance from psychologic findings. The psychologic effects of chronic pain are virtually indistinguishable from neurotic reactions in which pain is a symptom. Just as acute pain and anxiety share common features (autonomic reactions), so chronic pain and depression have similar patterns (vegetative changes). Attempts have been made to use psychologic tests to distinguish psychogenic from somatogenic, or functional from organic disorders. The attempts have failed and a headache scale on the MMPI did not prove helpful. Psychologic tests give a psychologic diagnosis with an estimate of the severity of the disturbance. The MMPI is a widely used psychologic test; it can give psychologic diagnosis, and has a number of other scales of interest also. Among these are a scale of addiction-proneness, and an ego-strength scale which predicts resistance to emotional disorder and the likelihood of favorable response to treatment. The MMPI can indicate whether an affective disorder or thought disturbance exists, and the need for psychotropic medications. Thus the emphasis is less on the importance of psychologic factors in the etiology of headache, and more on psychologic findings in need of treatment, regardless of causation. A number of brief tests supplement the MMPI and provide information on chronic invalidism, resentment towards doctors, adaptive or maladaptive illness behavior, if health concern reflects mere symptom preoccupation, disease phobia, or conviction of serious illness. The Health Index, a 50-item questionnaire with scales of chronic invalidism, manifest depression, pain preoccupation, and problems with health professionals. We now use an expanded Illness Behavior Questionnaire, a single 80-item Health Index with eleven scales permitting clinical description of the patient. This information can provide a profile of the psychologic state of the patient. It can suggest the need for psychiatric treatment, whether it is likely to be accepted by the patient, and the probability of success of any treatment. INTERVIEW The clinical psychologic interview focuses on the impact of the headache on daily activities. Generally, headaches are less disabling than other
syndromes encountered in a pain clinic, but there are exceptions, and of importance is the degree to which the headaches are intermittent or constant. Emphasis on the disruptive effect of the headaches give the psychologist insight whether and to what extent interpersonal relationships are affected at home and/or work. This identifies sources of stress within these relationships, and indirectly suggests whether there may be conflicts within the patient. Much is determined by how the patient answers and by the content of the answers. Possible games which may reinforce headache symptoms, and the degree to which the patient may be open to psychologic interpretation are assessed. Thus psychologic tests give the nature and degree of psychopathology, and the clinical interview the specific content of the stresses and conflicts. Whether the headaches are psychologic or somatic in origin is less important than whether there are significant psychologic or physical findings. Abnormalities in each area require treatment intervention in parallel, ignoring causation. The issue of which came first, the psychologic or physical factors, is of theoretical interest but of little practical consequence. The combined psychologic findings from test results and interview lead to treatment. Treatment includes psychotropic agents, psychotherapy, situational adjustments, or behavioral therapies. Sometimes brief psychotherapy occurs, in the form of crisis intervention, during the diagnostic interview. An example of psychologic evaluation, a composite of several actual case reports is given below. PSYCHOLOGIC EVALUATION A short, plump, very pleasant woman of 56, in no distress during our interview, eventually became tearful in describing the desperateness of her situation. She has had mixed muscle contraction and vascular headaches for some time. The muscle contraction headaches appear to be associated with degenerative disease and spurring of the cervical vertebrae and can also trigger the vascular headaches. A number of treatments have provided some relief. Recently, however, she has had an increased severity, frequency and duration of her head pains. She has been severely depressed, and was finally persuaded by her family physician to see a psychiatrist. For six sessions she knew nothing of what happened to her because the psychiatrist gave her sodium pentothal and several hours later a nurse would awaken her. At the end of the sixth session she requested some information and was told she needed electroshock therapy because she was not cooperative. She did not pursue this further. The patient also had biofeedback training for muscle relaxation and she practices this technique. She feels that it does help and she is not so depressed as she was formerly. However, biofeedback training has not helped her vascular headaches very much. Her hands and feet become very cold when she is having severe headaches and she frequently has body chills. She had such severe circulatory problems with her feet that she went to see a dermatologist because of the discoloration. He told her that the blotchiness was a vascular rather than dermatologic problem. The patient is not now taking any antidepressant medications. She was on desipramine for about a year and one-half and did much better; however, she gained weight and is still trying to lose the weight. She says she is still "depressed" because she really enjoys keeping up her home and garden, having the grandchildren over, etc., but the headaches interfere with this activity. Psychologic tests: The Health Index showed moderate chronic invalidism, slight manifest depression, moderate pain preoccupation, and slight disappointment with doctors for not having helped the pain. The overall pattern was one of moderate impact of pain on daily activities and some psychologic reaction to this. On the Whiteley Index of Hypochondriasis, she scored only slightly lower than average for psychiatric hypochondfiacal patients. Her serious health concern consists of severe symptoms preoccupation, but there is also some disease phobia and conviction of the presence of serious illness. The MMPl was taken defensively, the patient attempting to portray herself as conventional, virtuous, and emotionally stable. She has a strong need to see herself (and be seen by others) without even minor faults which most of us admit to. The clinical profile shows a striking chronic pain syndrome with marked focus on symptom preoccupation and excessive use of denial and repression.
This keeps her depressive reaction at borderline clinical significance, and is accompanied by a marginally important anxiety. A tendency to slight agitation, although not clinically significant, is also present. The tests show her very feminine, overly passive, who permits imposition and may even invite it, but then responds with resentment towards those who impose upon her. An introverted person, she cannot express her anger or assert herself, and this may contribute to her depressive reaction. The tests show her not addiction-prone, but she has little ego strength, and she may not respond to mere symptom alleviation without efforts directed at her psychologic state also. Impression: 1) Mixed muscle contraction and vascular headaches. 2) No psychiatric diagnosis- chronic pain syndrome with borderline anxious depressive reaction. Discussion and Recommendations: The patient is to return to biofeedback for training in temperature control. I believe this skill if practiced may reduce the frequency and severity of the vascular component of her head pain. Because her muscle contraction headaches may be triggered by spasms associated with cervical osteoarthritis, I have instructed her in the use of a transcutaneous electrical neurostimulator, placing a pair of electrodes high on either side of the cervical spine. She will be telephoning in one week to report on her progress. I do not believe that the patient is significantly disturbed. Although she calls her discouragement "depression", her anxious depressive reaction is not clinically significant. Therefore, psychotropic drugs are not indicated at present. TREATMENT MODALITIES Traditional psychotherapy, such as psychoanalysis and psychodynamic psychotherapy, have not been very successful for headache treatment. These therapies require some verbal ability and psychologic mindedness, are very expensive, slow, and limited to a small number of patients. What is needed is an efficient system for modifying the pathophysiologic processes in headache. Biofeedback provides such a system. Its usefulness is supported by animal and human experimental studies and in clinical settings. However, controlled follow-up studies are few, but suggest that motivated patients who continue to practice maintain therapeutic gains at an approximate 50% success rate. Part of the difficulty in biofeedback treatment of headache is choosing the underlying physiologic variable to "feed back" to the patient. It was thought that frontalis muscle relaxation was useful in all muscle contraction headache. Now it appears, however, that cervical paraspinal muscles are more appropriate in some patients. Similarly, hand-warming techniques do not apply to all vascular headaches. Peripheral vascular changes do not occur in all vascular headaches, and another variable must be found for these forms of headache. In addition to biofeedback, other techniques may be of value. Aversion conditioning may be helpful in blephorospasm and bruxism and transcutaneous electrical neurostimulation may help in degenerative disc disease of the cervical spine. RESEARCH In addition to giving diagnostic information and behavioral treatment, the psychologist can evaluate ongoing treatment and design experimental research. His training in experimental design and statistical analysis may be useful for controlled outcome studies of a treatment procedure, or to clinically test the effectiveness of a drug without sacrificing the methodology of a proper experiment. Research in a clinical setting is difficult but this challenge and the hard-nosed skepticism which it entails, frequently improves patient care.
