Living with chronic headache
Ciere, Yvette
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Ciere, Y. (2018). Living with chronic headache: A personal goal and self-regulation perspective. University of Groningen.
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Activity interference in chronic migraine
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Impaired mood in headache clinic patients:
associations with the perceived hindrance and
attainability of personal goals
Yvette Ciere, Annemieke Visser, John Lebbink, Robbert
Sanderman, Joke Fleer
Headache, 2016, 56 (6)
Chapter
ABSTRACT
Background: Headache disorders are often accompanied by impaired mood, especially in
the headache clinic population. There is a large body of literature demonstrating that an illness or disability may affect the way in which patients perceive their personal goals and that the perception that the attainability of goals is hindered by the illness is a risk factor for impaired mood. However, empirical evidence regarding the extent to which goals are hindered or less attainable as a result of a headache disorder, and how that is related to mood, is currently lacking.
Objective: The aim of this cross-sectional study was to examine associations between
headache severity, goal hindrance and attainability, and mood in a headache clinic population.
Methods: The sample consisted of 65 adult patients seeking treatment at a tertiary
headache clinic. Prior to their first appointment in the clinic, patients completed self-report measures of headache severity, goals and mood (PANAS).
Results: Higher self-reported headache intensity was associated with higher goal hindrance
(r = .38, p = .004), whereas greater headache frequency was associated with lower goal attainability (r = .30, p = .022). Higher perceived goal hindrance was associated with lower positive mood (r = -.27, p= .032) and higher negative mood (r = .28, p = .027).
Furthermore, lower perceived goal attainability was associated with higher negative mood (r = -.34, p = .007). Goal perceptions explained an additional 11.4% of the variance in positive mood (F=3.250, p = .047 <.05) and 10.5% of the variance in negative mood (F=3.459, p = .039) beyond the effect of age and headache severity.
Conclusion: The results of this preliminary study suggest that perceptions of increased goal
hindrance and decreased goal attainability may indeed be a risk factor for impaired mood in the headache clinic population and highlight the need for further, longitudinal research. Obtaining more insight into goal processes (e.g. what types of goals are specifically disturbed, which goal adjustment strategies are (mal)adaptive) may help to identify ways to improve outcomes in the headache clinic population.
INTRODUCTION
The association between headache disorders and impaired mood is well established. Headache disorders have been associated with elevated levels of negative mood (Holroyd et al., 2000; Louter et al., 2015) and lowered positive mood (Louter et al., 2015). Moreover, the occurrence of mood disorders is higher in patients with a headache disorder compared to controls, especially in those with chronic forms of headache (Buse, Silberstein, Manack, Papapetropoulos, & Lipton, 2013; Heckman & Holroyd, 2006). For example, reported prevalence rates in patients with chronic migraine range from 13-47% for both depression and anxiety disorders (Buse et al., 2013). Furthermore, depression and anxiety disorders have been found to occur in respectively 10-59% and 23-56% of patients with chronic tension-type headache (Holroyd et al., 2000; Juang, Wang, Fuh, Lu, & Su, 2000; Mongini, Ciccone, Deregibus, Ferrero, & Mongini, 2004; Puca et al., 1999). Impaired mood has been found to have a negative impact on patient functioning, as demonstrated by its associations with headache chronification (Ashina et al., 2012), medication-overuse (Lake, 2006) and higher headache-related impairment in daily life (Holroyd et al., 2000; Marcus, 2000). Hence, addressing mood impairments may improve treatment outcomes, particularly in headache clinic patients in which mood problems are especially common (Cassidy, Tomkins, Hardiman, & O'Keane, 2003).
There is a large body of literature highlighting the central role of personal goals in the adjustment to illness or disability, including chronic pain (Hamilton, Karoly, & Kitzman, 2004; Hullmann, Robb, & Rand, 2015; Stanton, Revenson, & Tennen, 2007; Van Damme, Crombez, Goubert, & Eccleston, 2009). Personal goals are self-defined plans or projects that may range from daily activities (e.g., exercising regularly) to activities that define one as a person (e.g., being successful in one’s occupation) (Austin & Vancouver, 1996; Little & Chambers, 2004). According to self-regulation theories (Carver & Scheier, 2001; Diener, Suh, Lucas, & Smith, 1999; Emmons, 1996; Little & Chambers, 2004), mood is strongly determined by the perception of progress towards personal goals. Yet, physical symptoms or limitations may interfere with the pursuit of personal goals which heightens the risk of mood disturbances. Indeed, it has been found that patients with an illness or disability perceive their goals as less attainable and/or more hindered by their physical condition and these goal perceptions are related to impaired mood (Boersma, Maes, & van Elderen, 2005; Janse, Sprangers, Ranchor, & Fleer, 2015; Kuenemund et al., 2013; Schwartz & Drotar, 2009; Van der Veek, Kraaij, Van Koppen, Garnefski, & Joekes, 2007).
The high level of disability found in patients presenting to headache clinics (Cassidy et al., 2003; Leonardi, Raggi, Bussone, & D'Amico, 2010) suggests that these patients may experience significant impediments to goal pursuit. Hence, negative goal perceptions may act as a risk factor for impaired mood in the headache clinic population. Notably, since goals and goal perceptions are modifiable, intervening on patients’ goals in treatment may improve treatment outcomes (Michalak & Holtforth, 2006; Sivaraman Nair, 2003).
ABSTRACT
Background: Headache disorders are often accompanied by impaired mood, especially in
the headache clinic population. There is a large body of literature demonstrating that an illness or disability may affect the way in which patients perceive their personal goals and that the perception that the attainability of goals is hindered by the illness is a risk factor for impaired mood. However, empirical evidence regarding the extent to which goals are hindered or less attainable as a result of a headache disorder, and how that is related to mood, is currently lacking.
Objective: The aim of this cross-sectional study was to examine associations between
headache severity, goal hindrance and attainability, and mood in a headache clinic population.
Methods: The sample consisted of 65 adult patients seeking treatment at a tertiary
headache clinic. Prior to their first appointment in the clinic, patients completed self-report measures of headache severity, goals and mood (PANAS).
Results: Higher self-reported headache intensity was associated with higher goal hindrance
(r = .38, p = .004), whereas greater headache frequency was associated with lower goal attainability (r = .30, p = .022). Higher perceived goal hindrance was associated with lower positive mood (r = -.27, p= .032) and higher negative mood (r = .28, p = .027).
Furthermore, lower perceived goal attainability was associated with higher negative mood (r = -.34, p = .007). Goal perceptions explained an additional 11.4% of the variance in positive mood (F=3.250, p = .047 <.05) and 10.5% of the variance in negative mood (F=3.459, p = .039) beyond the effect of age and headache severity.
Conclusion: The results of this preliminary study suggest that perceptions of increased goal
hindrance and decreased goal attainability may indeed be a risk factor for impaired mood in the headache clinic population and highlight the need for further, longitudinal research. Obtaining more insight into goal processes (e.g. what types of goals are specifically disturbed, which goal adjustment strategies are (mal)adaptive) may help to identify ways to improve outcomes in the headache clinic population.
Impaired mood in headache clinic patients _________________________________________________________________________
INTRODUCTION
The association between headache disorders and impaired mood is well established. Headache disorders have been associated with elevated levels of negative mood (Holroyd et al., 2000; Louter et al., 2015) and lowered positive mood (Louter et al., 2015). Moreover, the occurrence of mood disorders is higher in patients with a headache disorder compared to controls, especially in those with chronic forms of headache (Buse, Silberstein, Manack, Papapetropoulos, & Lipton, 2013; Heckman & Holroyd, 2006). For example, reported prevalence rates in patients with chronic migraine range from 13-47% for both depression and anxiety disorders (Buse et al., 2013). Furthermore, depression and anxiety disorders have been found to occur in respectively 10-59% and 23-56% of patients with chronic tension-type headache (Holroyd et al., 2000; Juang, Wang, Fuh, Lu, & Su, 2000; Mongini, Ciccone, Deregibus, Ferrero, & Mongini, 2004; Puca et al., 1999). Impaired mood has been found to have a negative impact on patient functioning, as demonstrated by its associations with headache chronification (Ashina et al., 2012), medication-overuse (Lake, 2006) and higher headache-related impairment in daily life (Holroyd et al., 2000; Marcus, 2000). Hence, addressing mood impairments may improve treatment outcomes, particularly in headache clinic patients in which mood problems are especially common (Cassidy, Tomkins, Hardiman, & O'Keane, 2003).
There is a large body of literature highlighting the central role of personal goals in the adjustment to illness or disability, including chronic pain (Hamilton, Karoly, & Kitzman, 2004; Hullmann, Robb, & Rand, 2015; Stanton, Revenson, & Tennen, 2007; Van Damme, Crombez, Goubert, & Eccleston, 2009). Personal goals are self-defined plans or projects that may range from daily activities (e.g., exercising regularly) to activities that define one as a person (e.g., being successful in one’s occupation) (Austin & Vancouver, 1996; Little & Chambers, 2004). According to self-regulation theories (Carver & Scheier, 2001; Diener, Suh, Lucas, & Smith, 1999; Emmons, 1996; Little & Chambers, 2004), mood is strongly determined by the perception of progress towards personal goals. Yet, physical symptoms or limitations may interfere with the pursuit of personal goals which heightens the risk of mood disturbances. Indeed, it has been found that patients with an illness or disability perceive their goals as less attainable and/or more hindered by their physical condition and these goal perceptions are related to impaired mood (Boersma, Maes, & van Elderen, 2005; Janse, Sprangers, Ranchor, & Fleer, 2015; Kuenemund et al., 2013; Schwartz & Drotar, 2009; Van der Veek, Kraaij, Van Koppen, Garnefski, & Joekes, 2007).
The high level of disability found in patients presenting to headache clinics (Cassidy et al., 2003; Leonardi, Raggi, Bussone, & D'Amico, 2010) suggests that these patients may experience significant impediments to goal pursuit. Hence, negative goal perceptions may act as a risk factor for impaired mood in the headache clinic population. Notably, since goals and goal perceptions are modifiable, intervening on patients’ goals in treatment may improve treatment outcomes (Michalak & Holtforth, 2006; Sivaraman Nair, 2003).
However, empirical evidence regarding the extent to which goals are hindered or less attainable as a result of a headache disorder, and how that is related to mood, is currently lacking. Thus far, evidence has only been provided by studies in adolescents with headache (Massey, Garnefski, Gebhardt, & Van Der Leeden, 2009; Massey, Garnefski, Gebhardt, & van der Leeden, 2011; Massey, Garnefski, & Gebhardt, 2009) and in adult patients with other chronic pain conditions (Affleck et al., 1998; Karoly & Ruehlman, 1996; Mun, Karoly, & Okun, 2015). These studies indeed demonstrate that patients with chronic pain perceive their goals as more hindered and less attainable than do patients with episodic or no pain (Karoly & Ruehlman, 1996; Massey et al., 2009). Further, daily diary studies have found that on days with higher pain severity, patients experience greater interference in goal pursuit (Affleck et al., 1998; Mun et al., 2015). Finally, perceptions of higher goal hindrance and perceptions of lower goal attainability have been associated with lower positive and higher negative mood in the context of adolescent headache (Massey et al., 2011) and chronic pain (Affleck et al., 1998; Karoly & Ruehlman, 1996).
The present study aimed to explore associations between headache severity (i.e., frequency and intensity), goal hindrance and attainability and mood in adult patients presenting to a tertiary headache clinic. First, it was postulated that a higher number of headache days and higher headache intensity would be associated with higher perceived goal hindrance and lower goal attainability. Second, it was hypothesized that higher goal hindrance and lower attainability would be associated with lower positive and higher negative mood.
METHODS
Participants and procedure
In this cross-sectional observational study, patients were consecutively recruited from a tertiary headache clinic between December 2013 and December 2014. Due to unforeseen organizational changes, data-collection had to be stopped after December 2014. All newly referred patients of 18 years or older were approached for participation in order to include a sample representative of the headache clinic population. Patients were excluded from the study if they cancelled their first appointment, were referred to primary or secondary care after the first consultation or were unable to complete questionnaires due to insufficient command of the Dutch language or physical or mental disability.
New patients who were scheduled for an intake appointment in the clinic received written information about the study and were contacted by a researcher for further information and screening. After providing written informed consent, eligible patients completed study questionnaires on paper or via a secured web application in the month before their intake appointment. The Medical Ethical Committee of the University Medical Center Groningen waived the need for full ethical review.
Materials
Demographic and medical characteristics – Information on age, gender, marital status, education level and occupation was obtained by self-report. Data on diagnosis was extracted from medical files and classified into an International Classification of Headache Disorders III (ICHD-III) (Headache Classification Committee of the International
Headache Society (IHS, 2013) diagnosis by a neurologist (JL).
Headache severity –The number of headache days (i.e., headache frequency) as well as the average intensity of headache (i.e., headache intensity) in the past month were obtained by self-report. Headache intensity was assessed on a 10-point VAS scale with higher scores representing higher intensity. When headache severity was not reported, the information was extracted from patients’ headache diaries if available from their medical file (N=5).
Goal hindrance and attainability –Goal hindrance and attainability were assessed using a method developed by Emmons (Emmons, 1999). Following an instruction that goals are the plans/projects that people are working on and are aimed at the things they want to attain, maintain or avoid, patients were asked to list a maximum of five of their current goals.(Emmons, 1999) For each goal, they rated the extent to which they perceived the goal to be (i) attainable, and (ii) hindered by headache, on a scale of 1 (not at all
hindered/attainable) to 10 (completely hindered/attainable). Total scores for attainability and hindrance were obtained by computing mean scores across ratings for all listed goals.
For descriptive purposes, goals were categorized into life domains by two independent raters (YC and a trained research assistant): physical (e.g., improve health), psychological (e.g., aim for personal growth), social (e.g., spend time with friends and family),
achievement (e.g., work on career) and leisure (e.g., spend time on hobbies). Initial
agreement between the two raters was 91%. Disagreement was resolved through discussion with a third rater (a researcher with expertise in goals).
Mood – Positive and negative mood were measured with the Positive and Negative Affect Schedule (PANAS) (Watson, Clark, & Tellegen, 1988). The 20-item PANAS measured the extent to which patients experienced positive mood (e.g., interested, excited) and negative mood (e.g., upset, irritable) in the past two weeks on a scale of 1 (very slightly or not at all) to 5 (extremely). Total scores for positive and negative mood were obtained by summing the ten items for each subscale. The PANAS has been found to have adequate psychometric properties (Carvalho et al., 2013; Crawford & Henry, 2004; Merz et al., 2013; Ostir, Smith, Smith, & Ottenbacher, 2005; Watson et al., 1988) and is still frequently used in chronic pain research (Bąbel, 2015; Bruce et al., 2014; Mun et al., 2015; Taylor, Davis, & Zautra, 2013). Cronbach’s alpha in this sample was .89 for positive mood and .89 for negative mood.
Impaired mood in headache clinic patients
_________________________________________________________________________ However, empirical evidence regarding the extent to which goals are hindered or less attainable as a result of a headache disorder, and how that is related to mood, is currently lacking. Thus far, evidence has only been provided by studies in adolescents with headache (Massey, Garnefski, Gebhardt, & Van Der Leeden, 2009; Massey, Garnefski, Gebhardt, & van der Leeden, 2011; Massey, Garnefski, & Gebhardt, 2009) and in adult patients with other chronic pain conditions (Affleck et al., 1998; Karoly & Ruehlman, 1996; Mun, Karoly, & Okun, 2015). These studies indeed demonstrate that patients with chronic pain perceive their goals as more hindered and less attainable than do patients with episodic or no pain (Karoly & Ruehlman, 1996; Massey et al., 2009). Further, daily diary studies have found that on days with higher pain severity, patients experience greater interference in goal pursuit (Affleck et al., 1998; Mun et al., 2015). Finally, perceptions of higher goal hindrance and perceptions of lower goal attainability have been associated with lower positive and higher negative mood in the context of adolescent headache (Massey et al., 2011) and chronic pain (Affleck et al., 1998; Karoly & Ruehlman, 1996).
The present study aimed to explore associations between headache severity (i.e., frequency and intensity), goal hindrance and attainability and mood in adult patients presenting to a tertiary headache clinic. First, it was postulated that a higher number of headache days and higher headache intensity would be associated with higher perceived goal hindrance and lower goal attainability. Second, it was hypothesized that higher goal hindrance and lower attainability would be associated with lower positive and higher negative mood.
METHODS
Participants and procedure
In this cross-sectional observational study, patients were consecutively recruited from a tertiary headache clinic between December 2013 and December 2014. Due to unforeseen organizational changes, data-collection had to be stopped after December 2014. All newly referred patients of 18 years or older were approached for participation in order to include a sample representative of the headache clinic population. Patients were excluded from the study if they cancelled their first appointment, were referred to primary or secondary care after the first consultation or were unable to complete questionnaires due to insufficient command of the Dutch language or physical or mental disability.
New patients who were scheduled for an intake appointment in the clinic received written information about the study and were contacted by a researcher for further information and screening. After providing written informed consent, eligible patients completed study questionnaires on paper or via a secured web application in the month before their intake appointment. The Medical Ethical Committee of the University Medical Center Groningen waived the need for full ethical review.
Impaired mood in headache clinic patients _________________________________________________________________________
Materials
Demographic and medical characteristics – Information on age, gender, marital status, education level and occupation was obtained by self-report. Data on diagnosis was extracted from medical files and classified into an International Classification of Headache Disorders III (ICHD-III) (Headache Classification Committee of the International
Headache Society (IHS, 2013) diagnosis by a neurologist (JL).
Headache severity –The number of headache days (i.e., headache frequency) as well as the average intensity of headache (i.e., headache intensity) in the past month were obtained by self-report. Headache intensity was assessed on a 10-point VAS scale with higher scores representing higher intensity. When headache severity was not reported, the information was extracted from patients’ headache diaries if available from their medical file (N=5).
Goal hindrance and attainability –Goal hindrance and attainability were assessed using a method developed by Emmons (Emmons, 1999). Following an instruction that goals are the plans/projects that people are working on and are aimed at the things they want to attain, maintain or avoid, patients were asked to list a maximum of five of their current goals.(Emmons, 1999) For each goal, they rated the extent to which they perceived the goal to be (i) attainable, and (ii) hindered by headache, on a scale of 1 (not at all
hindered/attainable) to 10 (completely hindered/attainable). Total scores for attainability and hindrance were obtained by computing mean scores across ratings for all listed goals.
For descriptive purposes, goals were categorized into life domains by two independent raters (YC and a trained research assistant): physical (e.g., improve health), psychological (e.g., aim for personal growth), social (e.g., spend time with friends and family),
achievement (e.g., work on career) and leisure (e.g., spend time on hobbies). Initial
agreement between the two raters was 91%. Disagreement was resolved through discussion with a third rater (a researcher with expertise in goals).
Mood – Positive and negative mood were measured with the Positive and Negative Affect Schedule (PANAS) (Watson, Clark, & Tellegen, 1988). The 20-item PANAS measured the extent to which patients experienced positive mood (e.g., interested, excited) and negative mood (e.g., upset, irritable) in the past two weeks on a scale of 1 (very slightly or not at all) to 5 (extremely). Total scores for positive and negative mood were obtained by summing the ten items for each subscale. The PANAS has been found to have adequate psychometric properties (Carvalho et al., 2013; Crawford & Henry, 2004; Merz et al., 2013; Ostir, Smith, Smith, & Ottenbacher, 2005; Watson et al., 1988) and is still frequently used in chronic pain research (Bąbel, 2015; Bruce et al., 2014; Mun et al., 2015; Taylor, Davis, & Zautra, 2013). Cronbach’s alpha in this sample was .89 for positive mood and .89 for negative mood.
Data analysis
Data were analyzed using IBM SPSS statistics version 23. The criterion for statistical significance was set at p < .05 (two-tailed). Descriptive statistics were used to examine characteristics of the reported goals (number of goals, domain, hindrance, attainability). Pearson correlations were used to examine univariate associations between headache severity, goal hindrance and attainability and mood. Hierarchical Multiple Regression Analyses (MRA) were used to examine the extent to which headache severity and goal hindrance and attainability accounted for the variance in positive and negative mood, after controlling for relevant demographic and medical characteristics. Demographic/medical variables were included as covariates when they were significantly associated with both mood and goal hindrance and/or attainability (p < .05). Preliminary analyses were conducted to ensure no violations of assumptions of linearity, normality, multicollinearity and homoscedasticity. Missing scale items on the PANAS were imputed by the mean of available items if at least 50% of the items was present, which is a commonly used and valid method for handling missing scale items (Peyre, Leplège, & Coste, 2011; Shrive, Stuart, Quan, & Ghali, 2006). The total number of imputed items was 21: 13 items across 6 cases for positive mood and 8 items across 3 cases for negative mood.
Figure 1 - flowchart
RESULTS
During the inclusion period, 125 patients were informed about the study: eleven did not meet inclusion criteria and 45 refused participation (see figure 1). Of the 69 patients that gave informed consent, four patients did not provide data for goals or mood and were thus excluded from the analyses. Demographic and clinical characteristics of the sample (N=65) are presented in table 1. The average age was 41.3 (range=18-79). The majority of patients was female (69.2%), in a relationship (72.3%), had completed medium level education (58.5%), and was employed (55.4%). Fifty-one (51) patients (78.5%) met criteria for episodic migraine, three (4.5%) for chronic migraine, eight (12.3%) for episodic tension-type headache (TTH), 36 (55.4%) for chronic TTH and 17 (26.2%) for another diagnosis (e.g. cluster headache, post-traumatic headache). More than half of the patients (52.3%) had co-occurring migraine and TTH and 27 patients (41.5%) had (probable) medication-overuse headache.
Table 1 Demographic and clinical characteristics of the study sample (N= 65)
Impaired mood in headache clinic patients
_________________________________________________________________________
Data analysis
Data were analyzed using IBM SPSS statistics version 23. The criterion for statistical significance was set at p < .05 (two-tailed). Descriptive statistics were used to examine characteristics of the reported goals (number of goals, domain, hindrance, attainability). Pearson correlations were used to examine univariate associations between headache severity, goal hindrance and attainability and mood. Hierarchical Multiple Regression Analyses (MRA) were used to examine the extent to which headache severity and goal hindrance and attainability accounted for the variance in positive and negative mood, after controlling for relevant demographic and medical characteristics. Demographic/medical variables were included as covariates when they were significantly associated with both mood and goal hindrance and/or attainability (p < .05). Preliminary analyses were conducted to ensure no violations of assumptions of linearity, normality, multicollinearity and homoscedasticity. Missing scale items on the PANAS were imputed by the mean of available items if at least 50% of the items was present, which is a commonly used and valid method for handling missing scale items (Peyre, Leplège, & Coste, 2011; Shrive, Stuart, Quan, & Ghali, 2006). The total number of imputed items was 21: 13 items across 6 cases for positive mood and 8 items across 3 cases for negative mood.
Figure 1 - flowchart
Impaired mood in headache clinic patients _________________________________________________________________________
RESULTS
During the inclusion period, 125 patients were informed about the study: eleven did not meet inclusion criteria and 45 refused participation (see figure 1). Of the 69 patients that gave informed consent, four patients did not provide data for goals or mood and were thus excluded from the analyses. Demographic and clinical characteristics of the sample (N=65) are presented in table 1. The average age was 41.3 (range=18-79). The majority of patients was female (69.2%), in a relationship (72.3%), had completed medium level education (58.5%), and was employed (55.4%). Fifty-one (51) patients (78.5%) met criteria for episodic migraine, three (4.5%) for chronic migraine, eight (12.3%) for episodic tension-type headache (TTH), 36 (55.4%) for chronic TTH and 17 (26.2%) for another diagnosis (e.g. cluster headache, post-traumatic headache). More than half of the patients (52.3%) had co-occurring migraine and TTH and 27 patients (41.5%) had (probable) medication-overuse headache.
Table 1 Demographic and clinical characteristics of the study sample (N= 65)
Characteristics of the reported goals are presented in table 2. Patients listed an average of 2.8 (SD=1.3) goals. Goals in the physical domain (e.g., lose weight) were most
frequently reported (M=.80, SD=.81), followed by psychological (e.g., being able to relax) (M=.65, SD=.76), achievement (e.g., return to work) (M=.65, SD=.72), social (e.g., meet with friends more often) (M=.45, SD=.59) and leisure goals (e.g., plan nice activities) (M=.29, SD=.58). Patients reported an average headache-related hindrance of 7.1 (SD=1.8). Highest hindrance was reported for achievement goals (M=7.9, SD=2.2), whereas the lowest hindrance was reported for leisure goals (M=6.3, SD=3.0). Average attainability was 7.1 (SD=1.4). Compared to goals in other domains, achievement goals were rated as most attainable (M=7.4, SD=1.8) whereas psychological goals were least attainable (M=6.8, SD=1.9).
Table 2 Characteristics of personal goals
First, univariate associations between headache frequency and intensity and goal hindrance and attainability were examined. Headache frequency was negatively skewed. However, since transformation did not improve fit, the untransformed variable was included in the analyses. As shown in table 3, greater headache frequency was significantly associated with lower goal attainability (r= -.30, p = .022), but not with goal hindrance (r = .06, p = .660). On the other hand, higher headache intensity was associated with greater goal hindrance (r = .38, p= .004), but not with goal attainability (r = .-.07, p = .591). Thus, only part of our hypotheses was confirmed.
Second, the univariate associations between goal hindrance and attainability and mood were examined. Negative mood was substantially positively skewed; hence a logarithmic transformation was applied. As shown in table 3, greater goal hindrance was associated with lower positive mood (r= -.27, p = .032) and higher negative mood (r=.28, p = .027). Lower goal attainability was associated with higher negative mood (r = -.34, p = .007 but, contrary to expectations, not with positive mood (r = .07, p = .572).
Finally, hierarchical multiple regression analyses (MRA) examined the extent to which goal hindrance and attainability accounted for the variance in positive and negative mood beyond the variance explained by age and headache severity. Besides skewness in negative mood and headache frequency, no other violations of assumptions for MRA were detected. Age was the only demographic variable that was significantly associated with one of the predictors, i.e., goal hindrance (r = -.35, p = .005), and one of the outcome variables, i.e., negative mood (r = 0.27, p = .033). Gender, employment status, relationship status, and educational level were not significantly associated with either goal hindrance, goal attainability or mood. Thus, in addition to headache frequency and intensity, we controlled for age in the MRA.
Table 3 Correlations between headache severity, goal hindrance, goal attainability, and
mood
*<.05 **<.01
Impaired mood in headache clinic patients
_________________________________________________________________________ Characteristics of the reported goals are presented in table 2. Patients listed an average of 2.8 (SD=1.3) goals. Goals in the physical domain (e.g., lose weight) were most
frequently reported (M=.80, SD=.81), followed by psychological (e.g., being able to relax) (M=.65, SD=.76), achievement (e.g., return to work) (M=.65, SD=.72), social (e.g., meet with friends more often) (M=.45, SD=.59) and leisure goals (e.g., plan nice activities) (M=.29, SD=.58). Patients reported an average headache-related hindrance of 7.1 (SD=1.8). Highest hindrance was reported for achievement goals (M=7.9, SD=2.2), whereas the lowest hindrance was reported for leisure goals (M=6.3, SD=3.0). Average attainability was 7.1 (SD=1.4). Compared to goals in other domains, achievement goals were rated as most attainable (M=7.4, SD=1.8) whereas psychological goals were least attainable (M=6.8, SD=1.9).
Table 2 Characteristics of personal goals
First, univariate associations between headache frequency and intensity and goal hindrance and attainability were examined. Headache frequency was negatively skewed. However, since transformation did not improve fit, the untransformed variable was included in the analyses. As shown in table 3, greater headache frequency was significantly associated with lower goal attainability (r= -.30, p = .022), but not with goal hindrance (r = .06, p = .660). On the other hand, higher headache intensity was associated with greater goal hindrance (r = .38, p= .004), but not with goal attainability (r = .-.07, p = .591). Thus, only part of our hypotheses was confirmed.
Impaired mood in headache clinic patients _________________________________________________________________________ Second, the univariate associations between goal hindrance and attainability and mood were examined. Negative mood was substantially positively skewed; hence a logarithmic transformation was applied. As shown in table 3, greater goal hindrance was associated with lower positive mood (r= -.27, p = .032) and higher negative mood (r=.28, p = .027). Lower goal attainability was associated with higher negative mood (r = -.34, p = .007 but, contrary to expectations, not with positive mood (r = .07, p = .572).
Finally, hierarchical multiple regression analyses (MRA) examined the extent to which goal hindrance and attainability accounted for the variance in positive and negative mood beyond the variance explained by age and headache severity. Besides skewness in negative mood and headache frequency, no other violations of assumptions for MRA were detected. Age was the only demographic variable that was significantly associated with one of the predictors, i.e., goal hindrance (r = -.35, p = .005), and one of the outcome variables, i.e., negative mood (r = 0.27, p = .033). Gender, employment status, relationship status, and educational level were not significantly associated with either goal hindrance, goal attainability or mood. Thus, in addition to headache frequency and intensity, we controlled for age in the MRA.
Table 3 Correlations between headache severity, goal hindrance, goal attainability, and
mood
*<.05 **<.01
The results of the MRA for positive and negative mood are reported in table 4. Age, headache frequency and intensity accounted for only 0.9% of the variance in positive mood and 13.8% of the variance in negative mood. Goal perceptions explained an additional 11.4% of the variance in positive mood (F=3.250, p = .047 <.05) and 10.5% in negative mood (F=3.459, p = .039). Thus, goal perceptions had a significant impact on mood above and beyond the effect of age and headache severity. In the final model, only goal hindrance had a significant impact on positive mood (β= -1.63, p = .016) and goal attainability was the only significant predictor of negative mood (β= -.32, p = .019). Effect size for the model as a whole was small for positive mood (f2=.14) and medium for negative mood (f2=.32) (Cohen, 1988).
Table 4 Results of hierarchical multiple regression analyses for positive and negative mood
*p<.05
DISCUSSION
The aim of this study was to provide preliminary insight into the associations between headache severity, the perceived hindrance and attainability of goals, and mood in a headache clinic population. In line with previous studies in adolescents with headache (Massey et al., 2009) and adults with chronic pain (Karoly & Ruehlman, 1996), more severe (i.e., more intense or more frequent) headache was found to be associated with greater perceived hindrance of goals and lower perceived attainability. Furthermore, supporting studies on adolescent headache (Massey et al., 2011; Massey et al., 2009) and a larger body of literature on chronic illness/disability (Boersma et al., 2005; Janse et al., 2015; Van der Veek et al., 2007), higher perceptions of goal hindrance and lower perceptions of goal attainability were associated with impaired mood. Based on these findings we suggest that the perception of impediments to goal pursuit may indeed be a risk factor for impaired mood in the headache clinic population.
The finding that goal hindrance and attainability explained mood beyond the effect of headache severity alone suggests that the extent to which headache impacts on goal pursuit may in fact be a greater risk factor for impaired mood than headache itself. This finding is congruent with that of a diary study in adolescents in which goal frustration was a stronger predictor of day-to-day variation in mood than the presence of headache (Massey et al., 2011). It is possible that patients who are better able to manage the impact of headache on their goals (e.g., by adjusting their goals) may, regardless of the severity of headache, encounter fewer obstacles when pursuing their goals in daily life and thus experience fewer negative emotions (e.g., frustration, sadness) and more positive emotions (e.g., joy, satisfaction). However, it cannot be ruled out that goal perceptions and mood may also be reversely related. For example, negative mood may negatively bias perceptions of goal pursuit (Hamilton et al., 2004). Finally, it should be noted that, against our expectations, goal attainability was not associated with positive mood. It could be that the pleasure derived from goal pursuit may depend more on the kind of goals that are set (e.g., intrinsic or extrinsic, approach or avoidance) than on their attainability (Emmons, 1999).
The finding that headache intensity was only associated with goal hindrance (and not attainability), while headache frequency was only associated with goal attainability (and not hindrance), suggests that the intensity of headache and the number of headache days may affect goal pursuit in a different way. This finding adds to that of a study in which disability was associated with headache intensity but not frequency (Magnusson & Becker, 2003). We speculate that the relation between headache intensity and hindrance, in the absence of a relation with attainability, is plausible in the context of highly intense but episodic headaches (e.g., episodic migraine) where in the presence of headache life is completely disrupted, but lost time can be compensated on “headache-free days” (and thus goals remain attainable). Conversely, the relation between headache frequency and attainability, but not hindrance, may be explained in the context of frequent but mild headache (e.g., chronic tension-type headache) where patients may be able to continue daily activities on
Impaired mood in headache clinic patients
_________________________________________________________________________ The results of the MRA for positive and negative mood are reported in table 4. Age, headache frequency and intensity accounted for only 0.9% of the variance in positive mood and 13.8% of the variance in negative mood. Goal perceptions explained an additional 11.4% of the variance in positive mood (F=3.250, p = .047 <.05) and 10.5% in negative mood (F=3.459, p = .039). Thus, goal perceptions had a significant impact on mood above and beyond the effect of age and headache severity. In the final model, only goal hindrance had a significant impact on positive mood (β= -1.63, p = .016) and goal attainability was the only significant predictor of negative mood (β= -.32, p = .019). Effect size for the model as a whole was small for positive mood (f2=.14) and medium for negative mood (f2=.32) (Cohen, 1988).
Table 4 Results of hierarchical multiple regression analyses for positive and negative mood
*p<.05
Impaired mood in headache clinic patients _________________________________________________________________________
DISCUSSION
The aim of this study was to provide preliminary insight into the associations between headache severity, the perceived hindrance and attainability of goals, and mood in a headache clinic population. In line with previous studies in adolescents with headache (Massey et al., 2009) and adults with chronic pain (Karoly & Ruehlman, 1996), more severe (i.e., more intense or more frequent) headache was found to be associated with greater perceived hindrance of goals and lower perceived attainability. Furthermore, supporting studies on adolescent headache (Massey et al., 2011; Massey et al., 2009) and a larger body of literature on chronic illness/disability (Boersma et al., 2005; Janse et al., 2015; Van der Veek et al., 2007), higher perceptions of goal hindrance and lower perceptions of goal attainability were associated with impaired mood. Based on these findings we suggest that the perception of impediments to goal pursuit may indeed be a risk factor for impaired mood in the headache clinic population.
The finding that goal hindrance and attainability explained mood beyond the effect of headache severity alone suggests that the extent to which headache impacts on goal pursuit may in fact be a greater risk factor for impaired mood than headache itself. This finding is congruent with that of a diary study in adolescents in which goal frustration was a stronger predictor of day-to-day variation in mood than the presence of headache (Massey et al., 2011). It is possible that patients who are better able to manage the impact of headache on their goals (e.g., by adjusting their goals) may, regardless of the severity of headache, encounter fewer obstacles when pursuing their goals in daily life and thus experience fewer negative emotions (e.g., frustration, sadness) and more positive emotions (e.g., joy, satisfaction). However, it cannot be ruled out that goal perceptions and mood may also be reversely related. For example, negative mood may negatively bias perceptions of goal pursuit (Hamilton et al., 2004). Finally, it should be noted that, against our expectations, goal attainability was not associated with positive mood. It could be that the pleasure derived from goal pursuit may depend more on the kind of goals that are set (e.g., intrinsic or extrinsic, approach or avoidance) than on their attainability (Emmons, 1999).
The finding that headache intensity was only associated with goal hindrance (and not attainability), while headache frequency was only associated with goal attainability (and not hindrance), suggests that the intensity of headache and the number of headache days may affect goal pursuit in a different way. This finding adds to that of a study in which disability was associated with headache intensity but not frequency (Magnusson & Becker, 2003). We speculate that the relation between headache intensity and hindrance, in the absence of a relation with attainability, is plausible in the context of highly intense but episodic headaches (e.g., episodic migraine) where in the presence of headache life is completely disrupted, but lost time can be compensated on “headache-free days” (and thus goals remain attainable). Conversely, the relation between headache frequency and attainability, but not hindrance, may be explained in the context of frequent but mild headache (e.g., chronic tension-type headache) where patients may be able to continue daily activities on
headache-days but still experience limitations in daily functioning (e.g., ability to
concentrate) which may, in the long run, result in lower goal attainability. Due to the high headache co-morbidity and small sample size, these hypotheses could not be tested in the current study. Hence, they should be examined in future research.
Perceptions of goal hindrance in this sample were higher than those found in patients diagnosed with colorectal cancer (Janse et al., 2015) and early stage breast cancer (Stefanic, Caputi, & Iverson, 2014). The finding that physical goals, which were often related to the headache (e.g. getting rid of the headache), were most frequently reported reflect this high burden of physical problems. Despite the high perceived hindrance due to headache, reported goals were perceived as rather attainable. In particular achievement goals were rated as both highly hindered and highly attainable. An explanation for this finding may be that patients use compensatory strategies to pursue goals related to work/school despite perceived difficulties (Schmitz, Saile, & Nilges, 1996). For example, they may invest all resources (e.g., time, energy) in these goals or find alternative ways to divide resources (e.g., adjust planning). The low proportion of social and leisure goals suggests that these compensatory strategies may come at the cost of goals in other life domains, however, these suggestions need further empirical examination.
The results of this study suggest that promoting successful goal pursuit in headache clinic patients may benefit mood and thus overall treatment outcome. For the whole treatment team, it may therefore be important to identify and help patients reduce barriers to goal pursuit (e.g., by optimizing medication or improving self-management). On the other hand, it may be necessary to manage beliefs and expectations regarding the outcome of treatment so that patients do not continue to pursue unattainable goals (e.g., getting rid of headache). Furthermore, it should be noted that conflicts between treatment goals (e.g., reducing use of Triptans) and personal goals (e.g., keeping full-time job) may negatively affect treatment motivation and, as a consequence, treatment adherence (Michalak & Holtforth, 2006; Sivaraman Nair, 2003). Motivational interviewing (Miller, 1983) may assist in resolving such conflicts (Rubak, Sandbaek, Lauritzen, & Christensen, 2005). Finally, psychological interventions such as Mindfulness-Based Cognitive Therapy or Acceptance and Commitment Therapy may help patients cope with headache-related limitations and set attainable goals (Thompson & McCracken, 2011). Indeed, several pilot studies have supported the effect of these interventions on mood and disability (Day et al., 2014; Dindo, Recober, Marchman, O'Hara, & Turvey, 2014; Mo'tamedi, Rezaiemaram, & Tavallaie, 2012; Wells et al., 2014).
To our knowledge, this was the first study to examine perceptions of goal pursuit in a headache clinic population. By taking patients’ goals as a focal point, we focused on those activities that are personally salient and are thus most likely to affect mood (Cantor et al., 1991; Lavallee & Campbell, 1995; Oishi, Diener, Suh, & Lucas, 1999). Further, by operationalizing mood as a dimensional construct, rather than as the absence or presence of a mood disorder, we encompassed a broad spectrum of emotions (both positive and negative) that may better reflect the normal daily experience of patients. Nevertheless,
several limitations should be noted. First, the cross-sectional design did not allow examination of the direction of associations. Second, as this study was conducted in a headache clinic population in which headache severity and disability are generally high, findings are not generalizable to other headache patients. Third, data of non-responders was not available. Hence, it cannot be ruled out that the most severely affected patients may have refused participation. Fourth, global self-report measures of headache severity are more susceptible to self-report bias than headache diaries. For example, patients who are currently in pain may overestimate their pain in the past month (Andrasik, Lipchik, McCrory, & Wittrock, 2005; Penzien et al., 2005).
The results of the present study highlight the need for further research. First, this study needs replication in larger samples. Second, researchers should use longitudinal designs to study the (possibly reciprocal) relationships between headache severity, goal appraisals and mood over time. In addition, intensive longitudinal designs (e.g., ecological momentary assessment (Shiffman, Stone, & Hufford, 2008)) could shed light on the way in which hindrance to goals may act as a daily stressor. Third, future studies may address other aspects of goal pursuit such as the conflict between personal goals and treatment goals (Karoly, 1999), goal orientation (e.g., the pursuit of pain-avoidance goals) (Van Damme & Kindermans, 2015) and the use of strategies to cope with headache-related goal interference (e.g., prioritization, scaling back goals) (Wrosch, Scheier, Miller, Schulz, & Carver, 2003). More insight into goal processes in the headache clinic population may benefit treatment as they may be a pathway to improved functioning without a necessary reduction in headache severity.
Impaired mood in headache clinic patients
_________________________________________________________________________ headache-days but still experience limitations in daily functioning (e.g., ability to
concentrate) which may, in the long run, result in lower goal attainability. Due to the high headache co-morbidity and small sample size, these hypotheses could not be tested in the current study. Hence, they should be examined in future research.
Perceptions of goal hindrance in this sample were higher than those found in patients diagnosed with colorectal cancer (Janse et al., 2015) and early stage breast cancer (Stefanic, Caputi, & Iverson, 2014). The finding that physical goals, which were often related to the headache (e.g. getting rid of the headache), were most frequently reported reflect this high burden of physical problems. Despite the high perceived hindrance due to headache, reported goals were perceived as rather attainable. In particular achievement goals were rated as both highly hindered and highly attainable. An explanation for this finding may be that patients use compensatory strategies to pursue goals related to work/school despite perceived difficulties (Schmitz, Saile, & Nilges, 1996). For example, they may invest all resources (e.g., time, energy) in these goals or find alternative ways to divide resources (e.g., adjust planning). The low proportion of social and leisure goals suggests that these compensatory strategies may come at the cost of goals in other life domains, however, these suggestions need further empirical examination.
The results of this study suggest that promoting successful goal pursuit in headache clinic patients may benefit mood and thus overall treatment outcome. For the whole treatment team, it may therefore be important to identify and help patients reduce barriers to goal pursuit (e.g., by optimizing medication or improving self-management). On the other hand, it may be necessary to manage beliefs and expectations regarding the outcome of treatment so that patients do not continue to pursue unattainable goals (e.g., getting rid of headache). Furthermore, it should be noted that conflicts between treatment goals (e.g., reducing use of Triptans) and personal goals (e.g., keeping full-time job) may negatively affect treatment motivation and, as a consequence, treatment adherence (Michalak & Holtforth, 2006; Sivaraman Nair, 2003). Motivational interviewing (Miller, 1983) may assist in resolving such conflicts (Rubak, Sandbaek, Lauritzen, & Christensen, 2005). Finally, psychological interventions such as Mindfulness-Based Cognitive Therapy or Acceptance and Commitment Therapy may help patients cope with headache-related limitations and set attainable goals (Thompson & McCracken, 2011). Indeed, several pilot studies have supported the effect of these interventions on mood and disability (Day et al., 2014; Dindo, Recober, Marchman, O'Hara, & Turvey, 2014; Mo'tamedi, Rezaiemaram, & Tavallaie, 2012; Wells et al., 2014).
To our knowledge, this was the first study to examine perceptions of goal pursuit in a headache clinic population. By taking patients’ goals as a focal point, we focused on those activities that are personally salient and are thus most likely to affect mood (Cantor et al., 1991; Lavallee & Campbell, 1995; Oishi, Diener, Suh, & Lucas, 1999). Further, by operationalizing mood as a dimensional construct, rather than as the absence or presence of a mood disorder, we encompassed a broad spectrum of emotions (both positive and negative) that may better reflect the normal daily experience of patients. Nevertheless,
Impaired mood in headache clinic patients _________________________________________________________________________ several limitations should be noted. First, the cross-sectional design did not allow
examination of the direction of associations. Second, as this study was conducted in a headache clinic population in which headache severity and disability are generally high, findings are not generalizable to other headache patients. Third, data of non-responders was not available. Hence, it cannot be ruled out that the most severely affected patients may have refused participation. Fourth, global self-report measures of headache severity are more susceptible to self-report bias than headache diaries. For example, patients who are currently in pain may overestimate their pain in the past month (Andrasik, Lipchik, McCrory, & Wittrock, 2005; Penzien et al., 2005).
The results of the present study highlight the need for further research. First, this study needs replication in larger samples. Second, researchers should use longitudinal designs to study the (possibly reciprocal) relationships between headache severity, goal appraisals and mood over time. In addition, intensive longitudinal designs (e.g., ecological momentary assessment (Shiffman, Stone, & Hufford, 2008)) could shed light on the way in which hindrance to goals may act as a daily stressor. Third, future studies may address other aspects of goal pursuit such as the conflict between personal goals and treatment goals (Karoly, 1999), goal orientation (e.g., the pursuit of pain-avoidance goals) (Van Damme & Kindermans, 2015) and the use of strategies to cope with headache-related goal interference (e.g., prioritization, scaling back goals) (Wrosch, Scheier, Miller, Schulz, & Carver, 2003). More insight into goal processes in the headache clinic population may benefit treatment as they may be a pathway to improved functioning without a necessary reduction in headache severity.
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