Chronic Headaches: Biology, Psychology, and Behavioral Treatment by Jonathan Borkum is the most r... more Chronic Headaches: Biology, Psychology, and Behavioral Treatment by Jonathan Borkum is the most recent of a relatively short list of books authored (not edited) by psychologists that address both the foundations of headache science and clinical management strategies from a behavioural medicine perspective (1–3). It is uncommon, worthwhile reading, combining scholarly comprehensiveness with a plethora of practical clinical suggestions and guidelines. And he writes with a crisp, direct and personal style that renders this lengthy tome fun to read. I found this book quite informative and thoughtprovoking, even after over 30 years of specialized headache practice. I suspect that it would evoke similar responses in other seasoned psychologists and behavioural medicine practitioners with an interest in pain and headache. However, its appeal should stretch well beyond that limited audience—it should also be of considerable interest to physicians and other healthcare providers who wish a deeper understanding of headache and the provision of comprehensive, state-of-the-art care for the headache sufferer. It would serve as an excellent text on behavioural treatment and its integration with headache medicine for advanced graduate students, fellows and residents. The book consists of 17 chapters, grouped into four sections: I. Foundations; II. Principle Types of Headaches: Physiology and Psychology; III. Clinical Guide to Headaches; and IV. Behavioral Medicine Treatment Outcome Literature. Each chapter begins with a literary or historical quotation. Important terms are boldfaced, and defined in an extensive glossary. References number just shy of 2000. Diagrams, tables, clinical forms and occasional protocols and scripts appear throughout the text. As a practising clinical psychologist, Borkum brings a unique perspective. For example, Chapter 2 (Pain Neurophysiology and Perception) begins with a clear exposition of nociception, progresses to the central nervous system including pain modulation, then concludes with the ‘The Pain System’s Inherent Psychology’. After noting that ‘. . . it is in the descending pathways, inhibitory and facilitory, that the full power of the central nervous system to control pain is realized’, he reviews the scientific literature on conditioned hyperalgesia, expectancy effects, stress-induced analgesia and exploratory behavior, all with an eye on the behavioural clinical implications. The following chapter (Psychological Variables in Chronic Pain) further explores the literature on attention and distraction in pain control, maladaptive pain coping, the intrusiveness of pain, catastrophizing and risk of chronicity, threat, priming, the placebo response, learned inhibition of pain, anxiety, depression and anger. He covers psychodynamic constructs including repression, conversion, somatization and alexithymia, then moves on to pain behaviour, operant conditioning, compensation and litigation, and developmental factors including the literature on history of abuse and chronic stress. He concludes with a discussion of ‘pain and meaning’, offering a brief comment on a unified model of chronic pain:
Journal of projective techniques and personality assessment, Feb 1, 1970
ABSTRACT The symmetry of Rorschach stimuli has led to some theorizing that balanced composition m... more ABSTRACT The symmetry of Rorschach stimuli has led to some theorizing that balanced composition may contribute to the production of M responses. In this study, Holtzman protocols from 95 Ss were analyzed for differences in number of M responses evoked by balanced versus unbalanced stimuli. An additional 30 protocols were obtained under conditions where symmetry was destroyed by masking half of the slide. Results indicated that symmetrical stimuli do not produce more M responses. This supports the idea that the M response originates on a level which is not directly influenced by the immediate environmental stimulation.
The common stressor faced by all headache sufferers is the headache itself. Dysfunctional headach... more The common stressor faced by all headache sufferers is the headache itself. Dysfunctional headache coping styles can be classified as sensitizing (hypervigilance and anticipation, catastrophizing, hyperempathy) or minimizing (alexithymia, stoic denial, anger suppression). Dysfunctional coping often takes place in an interpersonal context (theater of pain), marked by excessive pain behavior and embellishment, catastrophizing and hypervigilance in the family, stoicism and misinterpretation of pain, pain language as a substitute for emotional expression, or enabling of disability and pseudo‐coping. More adaptive coping styles include balanced use of distraction and body awareness, strategic proactive coping, balanced interpersonal discussion of pain, and pain acceptance. In addition to headache‐related research on coping styles, this article reviews relevant studies from neuroimaging, non‐headache chronic pain disorders, and clinical experience in a comprehensive, multidisciplinary headache center.
Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (heada... more Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency and severity, analgesic and abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for CBT of headache disorders. Controlled studies of CBTs for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of about 50%, roughly equivalent to propranolol. Cluster headache responds poorly to behavioral treatment. The persistent overuse of symptomatic medication impedes the effectiveness of behavioral and prophylactic medical therapies. Behavioral treatment can help sustain improvement after analgesic withdrawal, however, and prevent relapse in cases of analgesic overuse. Cognitive factors (e.g., an enhanced sense of self-efficacy and internal locus of control) appear to be important mediators of successful behavioral treatment. Patients with CDH are more likely to overuse symptomatic medication (and in some cases abuse analgesics), have more psychiatric comorbidity; have more functional impairment and disability, and are at least as likely to experience stress-related intensification of headache as patients whose episodic headaches occur less than 15 days per month. Despite the significance of these behavioral factors, patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Compliance-enhancement techniques, including behavioral contracts for patients with severe personality disorders, can increase adherence to behavioral recommendations. CBT has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache.
This article reviews all behaviorally oriented articles published in Headache from 1961(1:1) thro... more This article reviews all behaviorally oriented articles published in Headache from 1961(1:1) through the first 3 issues of 2008 and provides an analysis of trends in categories of articles by decade. A mean of 21.6% of all articles included significant attention to behavioral variables; this percentage was relatively stable from 1980 through 2008. The top 5 categories, accounting for 64% of all behavioral articles since the inception of Headache, were: behavioral treatment (19.2%), psychiatric comorbidity (14.0%), psychophysiology (11.2%), behavioral risk factors (9.8%), and psychobiological concepts (9.8%). There is an accelerating trend toward publication of articles related to psychiatric comorbidity, behavioral risk factors, and functional performance/disability.
My first personal encounter with frequent and troubling headaches involved one of my best friends... more My first personal encounter with frequent and troubling headaches involved one of my best friends, a boy I had known since preschool, and who in his early elementary school years would occasionally be unable to play due to headaches. At the time, I had difficulty even understanding what a headache was, since I had never experienced one. I had even more difficulty in understanding why his parents took him to a psychiatrist, although it intrigued my young mind to learn that there were doctors who just talked to people and tried to help them deal with problems. As we passed through adolescence, we took the same classes, shared the same interests in science, math, and English, went to camp, talked about girls, played in the school band, and had our own rock group. However, what I remember most vividly is not his headache disorder, but his combination of academic brilliance (a perfect 800 on the math SAT) and his frequent dysfunctional emotional displays. He was fun, witty, musically gifted, but prone to fits of anger. He
Chronic Headaches: Biology, Psychology, and Behavioral Treatment by Jonathan Borkum is the most r... more Chronic Headaches: Biology, Psychology, and Behavioral Treatment by Jonathan Borkum is the most recent of a relatively short list of books authored (not edited) by psychologists that address both the foundations of headache science and clinical management strategies from a behavioural medicine perspective (1–3). It is uncommon, worthwhile reading, combining scholarly comprehensiveness with a plethora of practical clinical suggestions and guidelines. And he writes with a crisp, direct and personal style that renders this lengthy tome fun to read. I found this book quite informative and thoughtprovoking, even after over 30 years of specialized headache practice. I suspect that it would evoke similar responses in other seasoned psychologists and behavioural medicine practitioners with an interest in pain and headache. However, its appeal should stretch well beyond that limited audience—it should also be of considerable interest to physicians and other healthcare providers who wish a deeper understanding of headache and the provision of comprehensive, state-of-the-art care for the headache sufferer. It would serve as an excellent text on behavioural treatment and its integration with headache medicine for advanced graduate students, fellows and residents. The book consists of 17 chapters, grouped into four sections: I. Foundations; II. Principle Types of Headaches: Physiology and Psychology; III. Clinical Guide to Headaches; and IV. Behavioral Medicine Treatment Outcome Literature. Each chapter begins with a literary or historical quotation. Important terms are boldfaced, and defined in an extensive glossary. References number just shy of 2000. Diagrams, tables, clinical forms and occasional protocols and scripts appear throughout the text. As a practising clinical psychologist, Borkum brings a unique perspective. For example, Chapter 2 (Pain Neurophysiology and Perception) begins with a clear exposition of nociception, progresses to the central nervous system including pain modulation, then concludes with the ‘The Pain System’s Inherent Psychology’. After noting that ‘. . . it is in the descending pathways, inhibitory and facilitory, that the full power of the central nervous system to control pain is realized’, he reviews the scientific literature on conditioned hyperalgesia, expectancy effects, stress-induced analgesia and exploratory behavior, all with an eye on the behavioural clinical implications. The following chapter (Psychological Variables in Chronic Pain) further explores the literature on attention and distraction in pain control, maladaptive pain coping, the intrusiveness of pain, catastrophizing and risk of chronicity, threat, priming, the placebo response, learned inhibition of pain, anxiety, depression and anger. He covers psychodynamic constructs including repression, conversion, somatization and alexithymia, then moves on to pain behaviour, operant conditioning, compensation and litigation, and developmental factors including the literature on history of abuse and chronic stress. He concludes with a discussion of ‘pain and meaning’, offering a brief comment on a unified model of chronic pain:
Journal of projective techniques and personality assessment, Feb 1, 1970
ABSTRACT The symmetry of Rorschach stimuli has led to some theorizing that balanced composition m... more ABSTRACT The symmetry of Rorschach stimuli has led to some theorizing that balanced composition may contribute to the production of M responses. In this study, Holtzman protocols from 95 Ss were analyzed for differences in number of M responses evoked by balanced versus unbalanced stimuli. An additional 30 protocols were obtained under conditions where symmetry was destroyed by masking half of the slide. Results indicated that symmetrical stimuli do not produce more M responses. This supports the idea that the M response originates on a level which is not directly influenced by the immediate environmental stimulation.
The common stressor faced by all headache sufferers is the headache itself. Dysfunctional headach... more The common stressor faced by all headache sufferers is the headache itself. Dysfunctional headache coping styles can be classified as sensitizing (hypervigilance and anticipation, catastrophizing, hyperempathy) or minimizing (alexithymia, stoic denial, anger suppression). Dysfunctional coping often takes place in an interpersonal context (theater of pain), marked by excessive pain behavior and embellishment, catastrophizing and hypervigilance in the family, stoicism and misinterpretation of pain, pain language as a substitute for emotional expression, or enabling of disability and pseudo‐coping. More adaptive coping styles include balanced use of distraction and body awareness, strategic proactive coping, balanced interpersonal discussion of pain, and pain acceptance. In addition to headache‐related research on coping styles, this article reviews relevant studies from neuroimaging, non‐headache chronic pain disorders, and clinical experience in a comprehensive, multidisciplinary headache center.
Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (heada... more Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency and severity, analgesic and abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for CBT of headache disorders. Controlled studies of CBTs for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of about 50%, roughly equivalent to propranolol. Cluster headache responds poorly to behavioral treatment. The persistent overuse of symptomatic medication impedes the effectiveness of behavioral and prophylactic medical therapies. Behavioral treatment can help sustain improvement after analgesic withdrawal, however, and prevent relapse in cases of analgesic overuse. Cognitive factors (e.g., an enhanced sense of self-efficacy and internal locus of control) appear to be important mediators of successful behavioral treatment. Patients with CDH are more likely to overuse symptomatic medication (and in some cases abuse analgesics), have more psychiatric comorbidity; have more functional impairment and disability, and are at least as likely to experience stress-related intensification of headache as patients whose episodic headaches occur less than 15 days per month. Despite the significance of these behavioral factors, patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Compliance-enhancement techniques, including behavioral contracts for patients with severe personality disorders, can increase adherence to behavioral recommendations. CBT has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache.
This article reviews all behaviorally oriented articles published in Headache from 1961(1:1) thro... more This article reviews all behaviorally oriented articles published in Headache from 1961(1:1) through the first 3 issues of 2008 and provides an analysis of trends in categories of articles by decade. A mean of 21.6% of all articles included significant attention to behavioral variables; this percentage was relatively stable from 1980 through 2008. The top 5 categories, accounting for 64% of all behavioral articles since the inception of Headache, were: behavioral treatment (19.2%), psychiatric comorbidity (14.0%), psychophysiology (11.2%), behavioral risk factors (9.8%), and psychobiological concepts (9.8%). There is an accelerating trend toward publication of articles related to psychiatric comorbidity, behavioral risk factors, and functional performance/disability.
My first personal encounter with frequent and troubling headaches involved one of my best friends... more My first personal encounter with frequent and troubling headaches involved one of my best friends, a boy I had known since preschool, and who in his early elementary school years would occasionally be unable to play due to headaches. At the time, I had difficulty even understanding what a headache was, since I had never experienced one. I had even more difficulty in understanding why his parents took him to a psychiatrist, although it intrigued my young mind to learn that there were doctors who just talked to people and tried to help them deal with problems. As we passed through adolescence, we took the same classes, shared the same interests in science, math, and English, went to camp, talked about girls, played in the school band, and had our own rock group. However, what I remember most vividly is not his headache disorder, but his combination of academic brilliance (a perfect 800 on the math SAT) and his frequent dysfunctional emotional displays. He was fun, witty, musically gifted, but prone to fits of anger. He
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