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jpomerantz February 17th, 2009 06:55 AM

Headache as symptom of anxiety
Hello, I am currently seeing a client that manifests classic anxiety symptoms such as shaking, loss of appetite, trouble concentrating, shortness of breath, feeling as if he's "cracking up"; but in addition has symptoms such as severe headache and, to a lesser degree, stomach ache.
Interestingly enough, the client's younger brother passed away from brain aneurism, and the headaches, quite predictably, invite catastrophic cognitions about "not waking up".
Medical workups - including CAT scan - are all 100% negative.
The client has also experienced a terrible headache subsequent to interoceptive exposure trial spinning on a chair (along with his full blown symptoms of shortness of breath etc).

My question at this point is: in addition to fostering an attitude of acceptance, teaching coping skills (relaxation, rational responding, coping self-statements etc), and doing exposure work - is there anything else that should be done to directly address the headache?? if doctors have found nothing can we really assume 100% that the headache is psychogenic? also, can headache symptoms be expected to "peak and pass" like other symptoms of anxiety, or will some other treatment be needed once a headache starts? in this kind of case is the use of pain medicaiton inconsistent with acceptance?
Any advice would be greatly appreciated!

James Pretzer February 20th, 2009 12:16 PM

Re: Headache as symptom of anxiety
Anxiety can produce a wide range of symptoms and sensations and both headaches and stomachaches are reasonably common ones.

No medical workup can 100% rule out the possibility of an undetected medical problem and headaches can have many causes. However, it seems likely that his main fear is that the headache is a sign that he is having an aneurysm or other medical emergency and my understanding is that an aneurysm would be detected by a CAT scan. Since interoceptive exposure produces the headache, this provides additional evidence that the headaches have mundane causes rather than being signs of a medical emergency.

On the question of whether his headaches can be expected to "peak and pass," yes, almost all headaches peak and pass eventually. However, that can take a while and headaches can be very uncomfortable until they do pass.

The question of whether using pain medication is inconsistent with acceptance or not is a tricky one. If his basic mindset is "This headache is terribly dangerous! I have to make it go away!" then using pain medication would be inconsistent with acceptance and would be likely to reinforce his fear of headaches. If his basic mindset is "Headaches are unpleasant events that happen from time to time, let me do what I can to cope with it until it passes," then taking Tylenol or another medication as one part of coping with the headache probably would not be a problem. However, the distinction between coping with the headache vs. desperately trying to make the headache go away can be a subtle one.

I hope this is helpful.

jpomerantz February 22nd, 2009 04:38 PM

Re: Headache as symptom of anxiety
Thanks so much for the post. I definitely was leaning in that direction - as you saw from my question - but it's reassuring to hear it from you as well :) I myself struggle with fully grasping the paradoxical concept of working to reduce - and at the same time - accept anxiety (and it's symptoms). I don't yet have a clean and crisp way of articulating and defining this for clients, perhaps there is none... I think that in the case of this client, carfully rationed and monitored use of the pain killers would be ok. He seems to get the idea of using the strategies we've gone through as "tools" vs. "weapons". I'll see how things develop and how successful the other strategies are (relaxation, rational responding etc) are before moving towards the pain meds as an adjunct.
Thanks again so much for your time in responding!

James Pretzer February 26th, 2009 05:01 PM

Re: Headache as symptom of anxiety
Clients often have a hard time grasping the idea of adopting an attitude of acceptance and coping towards panic attacks rather than trying to "fight" them. How can you accept something that feels as lousy as a panic attack? One analogy I use (after already having explained the panic cycle and having explained that panic attacks aren't dangerous) is the way that they deal with getting the flu.

When they notice that they're coming down with the flu is their reaction "Oh My God, the Flu! I have to fight it!"? Probably not. Their reaction is probably "Oh shit, the flu. Oh well, there's nothing to do but deal with it." They know that having the flu feels miserable but that there's nothing gained by treating it as an emergency. What they need to do is to cope with it as best they can until it passes.

Suppose they were to simply cope with the panic attack until it passes rather than trying to fight it, control it, or make it stop? What would happen then? When they try to fight the panic and are unsuccessful, they typically feel more helpless and out of control and this generally makes the panic attack more intense and prolongs it. If they simply tolerate the panic attack and let it run it's course, it will eventually pass. Since attempts to fight panic typically make the panic attack worse, if they tolerate it rather than fighting it, the panic may well be less intense and pass more quickly.

Just as they might they might be able to find some ways to cope with the flu until it passes (such as getting extra rest, drinking plenty of liquids, and watching a DVD to pass the time), we can explore what they can do to cope with the panic until it passes. However, the point isn't to make the panic stop, the point is to cope with panic until it passes.

How does that sound?

jpomerantz February 28th, 2009 06:30 PM

Re: Headache as symptom of anxiety
thanks again so much! that metaphor, to the flu, sounds incredibly useful indeed.

What I'm understanding is that, really, any interventions or coping skills are OK provided that the client's attitude is one of "cope with it, make myself comfortable and able to tolerate the symptom(s) till it passes" rather than "defeat it, make it go away, it is unacceptable / dangerous". that being said, certain strategies such as PRN benzos or even cognitive distraction are risky because the client can easily slip into using these to "get rid" of the anxiety feelings. am I understanding this correctly? technically, if they are less than convinced about the notion of acceptance, than even interventions such as rational responding can become "weapons" - I'm assuming the proof is in the pudding... if the client gets better, they must be doing it correctly. if they aren't, we need to go back and make sure that the tools we've given them aren't being "misused"

Just wanted to make sure I'm understanding clearly :-)

James Pretzer March 5th, 2009 10:55 PM

Re: Headache as symptom of anxiety
Yes, that's it.

James Pretzer March 10th, 2009 09:36 PM

A Useful Framework for Treatment Planning
In a recent article, Mark Boschen and Tai Oei present a case formulation framework for treatment planning of CBT with anxiety disorders. I haven't gone through it in detail yet but it looks like a useful aid in making sense of anxiety disorders and choosing among the many possible interventions.
  • Boschen, M. J. & Oei, T. P. S. (2008). A cognitive behavioral case formulation framework for treatment planning in anxiety disorders. Depression and Anxiety, 25, 811-823.

jpomerantz March 11th, 2009 05:23 AM

Re: Headache as symptom of anxiety
Thanks so much! I'll check that article out.

interestingly, in the next session, the client mentioned in passing that he's started using a ventalin inhaler... I asked him more about that and realized that he was trying to "fight" the feeling of shortness of breath. I explained to him that, the fact that he was feeling better only 5 mins or so after using it, in and of itself, shows that the medication was not what was making him feel better - it was the anxiety passing (as an asthmatic myself I know that those things either work pretty intantaneously or not at all...) - i explained how this was a prime example of NOT practicing acceptance. this really hit home for him and he told me that he's finally understanding what I'm talking about :) (the metaphor with the flu was very helpful as well).
thanks again so much!!

Sandra Paulsen April 3rd, 2009 10:43 AM

Re: Headache as symptom of anxiety
I'm sure there are stress/tension headaches that are symptoms of anxiety per se, but be aware that focal headaches that emerge during a session in direct response to an intervention are sometimes associated with an undiagnosed dissociative disorder. Sudden focal headaches that come and go can be associated with approach/avoidance conflicts associated with specific ego states. This can be tested with an ego state intervention designed to give a voice to the poles of a conflict. Those two poles can have quite different cognitions related to self-efficacy, expectations, distortions, even orientation to person place and time. Exploration of those dimensions can provide opportunities for intervention and the headaches can be both utilized as a source of information about internal states and resolved as conflicting beliefs are resolved.

jpomerantz April 8th, 2009 05:25 AM

Re: Headache as symptom of anxiety
interesting... thanks for sharing that persective. I have had clients develop panic symptoms in response to induction exercises... in this case, the client is seeking therapy due to a pretty long (year plus) history of headaches that induce highly anxious cognitions and low level panic attacks that can last hours.

as an update: he's been making some progress with a combination of cognitive restructuring, relaxation training, and imaginal flooding; he does not yet feel "ready" to do the imaginal exposures outside of sessions - I am hoping and predicting that when he's able and willing to engage in this more frequently between sessions, that we'll see more marked improvement.

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