HANDBOOK OF PSYCHOLOGY - PART 5 ppt

254 Headaches The prolonged presence of headache begins to exert a psy- chologicaltollonthepatientovertime,suchthatthepatientbe- comes •sick and tired of feeling sick and tired.ŽThe negative thoughts andemotions arising fromthe repeated experienceof headache thus can become further stressors or trigger factors in and of themselves (referred to as •headache-related distressŽ), serving at that point both to help maintain the disorder and to increase the severity and likelihood of future attacks. Pointing out the direct and indirect psychological in”uences on headache may make it easier for the patient to understand and accept therole of psychologicalfactors and canoften facilitate referral for adjunctive psychological/psychiatric care when needed (to illustrate, ask the patient which is worse, onset of a headache when the patient is refreshed and rested or when work and family frustrations are at a peak). This model points out the various areas to address when interviewing headache patients. Implementation Appropriate treatment implementation assumes adequate ex- pertise in the application of the interventions selected. Be- cause this chapter is intended for nonmedical practitioners, the following sections will address the application and imple- mentation of nonpharmacological, behavioral and cognitive behavioral, interventions that have garnered empirical sup- port to date. As previous sections have indicated, appropriate medical evaluation cannot be overlooked and pharmacologi- cal therapy may be the treatment of choice or a necessary component. When pharmacotherapy is used, ongoing med- ical assessment and collaboration with a quali“ed medical provider is critical (Blanchard & Diamond, 1996). A common element among all therapies is patient educa- tion, which begins at the onset andcontinues throughout treat- ment. Research by Packard (1987) reveals that information about headache is one of the top needs of patients when they come for treatment. Each of the following treatments begins with an educational component that typically in- cludes information on the etiology of headache, the rationale for treatment, and an explanation of what is involved with the particular treatment, as well as encouragement of active participation on the part of the patient (Andrasik, 1986, 1990; Holroyd & Andrasik, 1982). Therapists are encour- aged to discuss the aforementioned biobehavioral model of headache in clear, nontechnical terms. In the initial session emphasis is placed on the importance of collaboration between the therapist and patient and of reg- ular home practice to facilitate skill acquisition (Holroyd & Andrasik, 1982; Martin, 1993). Although strongly encour- aged, the role of home practice has received inconsistent support in the research literature. In clinical practice, the importance of home practice is emphasized, even though this may often be an unexamined assumption (Blanchard, Nicholson, Radnitz, et al., 1991; Blanchard, Nicholson, Taylor, et al., 1991). Relaxation Training Relaxation training for recurrent headache disorders may take a variety of forms. Two forms in particular have been widely applied in the treatment of recurrent headache disorders: pro- gressive muscle relaxation (e.g., Cox, Freundlich, & Meyer, 1975) and autogenic training (e.g., Sargent, Green, &Walters, 1973). Transcendental Meditation (Benson, Klemchuk, & Graham, 1974) and self-hypnosis (ter Kuile, Spinhoven, Linssen, & van Houwelingen, 1995) have also been applied, but not extensively. Progressive muscle relaxation training as applied to recur- rent headache disorders is most often based upon the work of Jacobson (1938) or Bernstein and Borkovec•s (1973) abbre- viated adaptation of Jacobson•s procedures. Progressive mus- cle relaxation may be used alone or in conjunction with biofeedback. Typically applied during 10 sessions over the course of eight weeks, the procedure involves therapist- guided training of patients to alternately tense and relax tar- get muscle groups. Patients are instructed to tense the target muscle group for “ve to ten seconds, focusing on the sensa- tions that result from the tension. Following the tension phase, patients are instructed to release the tension and relax the muscle for 20 to 30 seconds, again focusing on the sensa- tions associated with the release of tension. The tense/relax cycle instructions are repeated two to three times for each muscle group. As the patient becomes pro“cient at tensing and relaxing muscle groups, training proceeds to consolidate muscle groups, facilitate the deepening of relaxation, enhance abilities to discriminate among various levels of re- laxation, and induce relaxation by recall. Patients are typi- cally instructed to practice their relaxation exercises once or twice daily for 20 minutes. Table 11.5 from Andrasik (1986) and Tables 11.6 and 11.7 contain a summary of a typical protocol. Autogenic training was “rst applied to headache disorders (typically migraine) by Sargent et al. (1973).Autogenic train- ing (Schultz & Luthe, 1969) involves focusing on a set of phrases speci“cally designedto promote adesiredphysiologic state. Autogenic training for headache treatment utilizes phrases intended to elicit sensations of relaxation, heaviness, and warmth in the entire body (face/head, trunk, and extremi- ties) with a particular emphasis placed on warming of the hands. Autogenic training is often employed in conjunction Behavioral Treatment 255 TABLE 11.5 Outline of Progressive Muscle Relaxation Training Program Introduction Number of Muscle and Treatment Muscle Deepening Breathing Relaxing Discrimination Relaxation Cue-Controlled Week Session Rationale Groups Exercises Exercises Imagery Training by Recall Relaxation 11 X 14 X X 214XXX 23 14 X X X X 414XXXX 35 8 X X X X 68XXXXX 47 4 X X X X X 58 4 X X X X X X 69 4 X X X X X X 7 none 810 4 X X X X X X Source: Andrasik (1986). TABLE 11.6 Fourteen Initial Muscle Groups and Procedures for Tensing in 18 Steps 1. Right hand and lower arm (have client make “st, simultaneously tense lower arm). 2. Left hand and lower arm. 3. Both hands and lower arms. 4. Right upper arm (have client bring his or her hand to the shoulder and tense biceps). 5. Left upper arm. 6. Both upper arms. 7. Right lower leg and foot (have client point his or her toe while tensing the calf muscles). 8. Left lower leg and foot. 9. Both lower legs and feet. 10. Both thighs (have client press his or her knees and thighs tightly together). 11. Abdomen (have client draw abdominal muscles in tightly, as if bracing to receive a punch). 12. Chest (have client take a deep breath and hold it). 13. Shoulders and lower neck (have client •hunchŽ his or her shoulders or draw his or her shoulders up toward the ears). 14. Back of the neck (have the client press head backward against headrest or chair). 15. Lips/mouth (have client press lips together tightly, but not so tight as to clench teeth; or have client place the tip of the tongue on the roof of the mouth behind upper front teeth). 16. Eyes (have client close the eyes tightly). 17. Lower forehead (have client frown and draw the eyebrows together). 18. Upper forehead (have client wrinkle the forehead area or raise the eyebrows). TABLE 11.7 Abbreviated Muscle Groups Eight Muscle Groups 1. Both hands and lower arms. 2. Both legs and thighs. 3. Abdomen. 4. Chest. 5. Shoulders. 6. Back of neck. 7. Eyes. 8. Forehead. Four Muscle Groups 1. Arms. 2. Chest. 3. Neck. 4. Face (with a particular focus on the eyes and forehead). with thermal biofeedback, which also places an emphasis on warming of the hands, leading to a treatment termed •auto- genic feedbackŽby Sargent et al. (1973). Autogenic training involves the verbatim repetition of the selected phrases, “rst demonstrated by the therapist. Tape recordings of sessions or printed copiesof verbatim scriptsmay be helpfuluntil patients learn the phrases and their sequence as well as the ability to elicit the desired sensations. Biofeedback A number of biofeedback interventions have been applied to recurrent headache disorders, including: EMG, thermal, electrodermal, cephalic vasomotor, transcranial doppler, and EEG biofeedback (see Andrasik, 2000). EMG biofeedback and thermal biofeedback are described here, as these have the most empirical support and they are the biofeedback approaches most widely used in clinical practice (they are the •workhorsesŽ of the biofeedback •general practitionerŽ). The other approaches require more specialized training and equipment. EMG and thermal biofeedback interventions are com- monly employed in conjunction with relaxation training and/or autogenic training. As with relaxation training and au- togenic training, a rationale for ef“cacy is provided to the pa- tient at the start of biofeedback treatment (seeAndrasik, 1986, and Blanchard & Andrasik, 1985, for verbatim explanations). The therapist will often be present and active in •coachingŽ 256 Headaches the patient in early sessions of biofeedback but it has been suggested that the therapist•s presence, particularly if overly active orintrusive, canbecome adistraction and interfere with the training (Borgeat, Hade, Larouche, & Bedwani, 1980). Hence, biofeedback training is designed to be therapist- guided in the initial phases, with an effort to move in the direction of increased self-regulation on the part of the patient as training proceeds. For both types of biofeedback training described next, 8 to 16 sessionsof training are usually provided,typically between 20 and 40 minutes in duration (or long enough for training to be effective but brief enough to minimize the likelihood of fatigue). Instead of a universal prescriptive for the length of treatment, the number of sessionsis more usefully determined by the individual patient•s response to treatment. Training may be discontinued when maximum bene“t has been achieved, as in a signi“cant reduction in headache activity or when the reduction in headache activity plateaus or stabilizes. In some cases, a reduction of headache activity may not have occurred. Inthese cases, itmay be useful to determinewhether the patient has achieved suf“cient skill at physiological self- regulation of the target response. If the patient has achieved suf“cient skill and is able to apply these skills in real-life settings but has not experienced a reduction in headache activity, other treatment options may be indicated. EMG biofeedback is relatively straightforward and can be performed both in the clinic and at home with portable de- vices. The aim of EMG biofeedback training is to decrease muscle tension (as evidenced by electrical activity) of the frontal muscles of the forehead (e.g., Budzynski et al., 1973), although other muscles may be targeted in a similar fashion if these muscles appear to play an important role in the individ- ual•s headache activity. To achieve these aims, patients are encouraged to experiment with a variety of methods of phys- iological self-control (such as relaxation exercises, imagery exercises, or breathing exercises) while receiving feedback about their performance via an EMG device. Often, the train- ing portions of the biofeedback sessions proceed in brief in- tervals of 1 to 5 minutes in length, interspersed with brief pauses that provide an opportunity for rest periods and dis- cussion with the therapist. Across sessions, patients are encouraged to further increase and re“ne their self-regulatory skills in this manner. Thermal biofeedback also generally aims to increase phys- iological self-regulation. Speci“cally, the aim is to increase peripheral body temperature or a hand-warming response. To achieve these aims, patients are encouraged to experiment with a variety of methods of physiological self-control (such as relaxation exercises, imagery exercises, or breathing exer- cises) while receiving feedback about their “nger tempera- ture. Relaxation may be induced by recall prior to start of biofeedback session. Often, autogenic phrases or imagery are used during thermal biofeedback training sessions as a means of raising peripheral body temperature. An adaptation phase and baseline period are often used to note baseline tempera- ture, followed by training phases that proceed in short inter- vals characterized by voluntary efforts to warm the hands. Some have suggested that it may be bene“cial for patients to achieve a certain criterion level during training (e.g., be able to increase “nger temperature to a certain temperature value within a speci“ed period or for a speci“ed length; Fahrion, Norris, Green, Green, & Snarr, 1986). Although this makes sense from a clinical perspective, there is minimal data to support this notion. The mechanisms of action for these therapies are not fully clear, as the data suggest that the direction of change in EMG level and “nger temperature and extent of physiological control achieved are not predictive of outcome. Similarly, comparisons of relaxation therapies and biofeedback inter- ventions often “nd equivalence, suggesting that the effects are not speci“c to the type of therapy employed but rather due to nonspeci“c effects that may have an underlying relaxation mechanism (Cohen, McArthur, & Rickles, 1980; Primavera & Kaiser, 1992). It is possible that a generalized relaxation response or physiological self-control is the com- mon denominator and active ingredient in these therapies, rather than the directional change in a speci“c physiological process. Alternative explanations of the mechanism of action of these therapies have included alteration of cognitive and behavioral responses to stress and improved coping (Andrasik & Holroyd, 1980b) and cognitive changes such as an increased sense of perceived control and mastery (Cohen et al., 1980). Cognitive changes that may underlie the effec- tiveness of biofeedback may be mediated by performance feedback that suggests •successŽ (Holroyd, Penzien, Hursey, et al., 1984), allowing for increased perceptions of control and mastery. In short, research into the psychophysiological mechanisms of biofeedback has led to the suggestion that cognitive factors may play an important role in the ef“cacy of behavioral and physiological self-regulation interventions; however, our understanding of these mechanisms remains •rudimentaryŽ (Gauthier, Ivers, & Carrier, 1996). Cognitive Behavioral Interventions This type of therapy has been labeled variously as cognitive behavior therapy, cognitive stress coping therapy, cognitive therapy, stress management, or other terms. In addition to the evidence from biofeedback studies that suggests that cognitive factors play a role in the treatment of recurrent Behavioral Treatment Planning 257 headache disorders, there is also evidence to suggest that stress, appraisal of stress, and coping play a signi“cant role in recurrent headache disorders (Holm, Holroyd, Hursey, & Penzien, 1986; Lake, 2001). Theoretically, cognitive behav- ioral therapies may work by altering cognitive appraisals/ expectancies, stress responses, or cognitive/behavioral cop- ing responses, although the speci“c causal relationships between stress and headaches and cognitive therapies and headaches remain unclear (Morley, 1986). Much of the empirical study of cognitive behavioral interventions for recurrent headache disorders have adapted the traditional cognitive behavioral framework of Meichenbaum•s stress inoculation training as applied to pain (Meichenbaum, 1977; Turk, Meichenbaum, & Genest, 1983) or Beck•s cognitive therapy (Beck, Emery, & Greenberg, 1985; Beck, Rush, Shaw, & Emery, 1979). These traditional cognitive-behavioral therapies have been adapted speci“- cally for the treatment of recurrent headache disorders by Holroyd and Andrasik (1982) and Holroyd, Andrasik, and Westbrook (1977). It should be kept in mind that cognitive behavioral therapies for headache are most often applied in the form of a •treatment packageŽ that may include a number of the other approaches discussed previously. In CBT patients are taught a rationale that suggests that learning to identify and modify cognitions will mediate the stress-headache relationship. Unfortunately, empirical inves- tigation of these assumptions is very limited, as are data to support the validity of these assumptions. This led Morley (1986) to conclude that •this approach to treatment is open to the criticism that the therapy works because of a convincing rationale and not because the rationale is essentially correctŽ (p. 317). This conclusion still applies. Although CBT has been shown to be superior to no treatment and to be as good as (if not superior to) other effective treatments for headache, it is also unclear whether CBT is superior to a credible atten- tion placebo (Blanchard, 1992). While it is clear that much more investigation is required before this rationale can be claimed as validated, the data are also clear that cognitive be- havioral therapies possess ef“cacy in the treatment of recur- rent headache disorders, even if the mechanisms of action are poorly understood. Holroyd andAndrasik (1982) identify three general phases of CBT for headache disorders, including: education, self- monitoring, and problem-solving or coping skills training. For the most part, cognitive behavioral approaches to headache disorders are fairly consistent in their emphasis on education and self-monitoring. It is within the last phase that much of the variability exists. Once the rationale has been explained in suf“cient detail, CBT for headache disorders moves quickly into a very detailed form of self-monitoring. Patients are taught to monitor and record the factors that precede, accompany, and follow stressful situations and headaches. Patients are taught to monitor their thoughts (cognitions), feelings (emotions), behaviors, and sensations. This functional analysis of an- tecedents, concomitants, and consequences is intended as a means of identifying modi“able aspects of headache and stress. Emphasis is often placed on the antecedents and con- comitants of headache and stress, particularly cognitive and behavioral antecedents and concomitants because of the as- sumption that these may be amenable to modi“cation. The remainder of cognitive behavioral therapy focuses on modifying those factors that appear to be related to headache activity and stress. This phase of the therapy may vary substantially. A number of strategies and techniques may be used to modify the factors that were identi“ed through self- monitoring. Some of the most common cognitive strategies applied include cognitive restructuring and reappraisal (in the tradition of the Cognitive Therapy of Beck or Rational Emotive Therapy of Ellis) and the use of coping self- statements (in the tradition of Meichenbaum•s Stress Inocula- tion Training). Common to each of these approaches is the identi“cation and revision of maladaptive cognitions. Using any of these approaches, the therapist assists the patient in the review of self-monitoring data by helping the client identify maladaptive cognitions and challenge them effectively. Therapists may also assist in the identi“cation of maladaptive behavioral responses to stress and provide training and sup- port in the use of problem solving strategies to identify more adaptive behavioral responses to stress and headache. BEHAVIORAL TREATMENT PLANNING The empirical treatment outcome literature, pharmacological and nonpharmacological, provides a useful starting point for treatment planning with an individual patient. In addition to reporting on the overall ef“cacy of various treatments, this literature also offers some insights into individual factors that increase or decrease the likelihood of a clinically signi“- cant treatment response. Unlike treatment outcome studies that are con“ned by the restraints of empirical rigor for the purpose of hypothesis testing and maintenance of internal validity, clinical treatment of patients presenting with recur- rent headache disorders must rely on sound clinical judgment and careful selection of interventions that are most likely to provide the best treatment outcome for the individual. Whereas treatment outcome studies utilize a somewhat stan- dardized approach, optimal clinical treatment is not always suited by a •one-size-“ts-allŽ stance. The following sections 258 Headaches describe some of the individual factors that have been found to be related to treatment outcome and that can be useful in determining which of the numerous options for treatment might be particularly useful for an individual patient. These factors include: headache type, frequency, and chronicity; age and gender; comorbid psychological disorder or distress; environmental factors; and treatment history. Other factors, such as patient preference and cost effectiveness, have not received as much empirical attention, but these are nonethe- less important when considering treatment options. While much of the empirical literature has examined •intensiveŽ in- dividual therapy formats (typically 8 to 12 sessions), other methods of treatment delivery merit consideration, including reduced therapist contact and group treatments. Headache Type, Frequency, and Chronicity Both tension-type and migraine headache respond well to pharmacological and nonpharmacological treatments. With regard to nonpharmacological interventions, both headache types bene“t from relaxation training and cognitive behav- ioral interventions. Although thermal biofeedback is more widely applied to migraine headache and EMG biofeedback is more widely applied to tension-type headache, there is evidence to suggest that EMG biofeedback is also useful for migraine headache. Patients with mixed migraine and tension- type headaches also respond to the treatments discussed above, although typically not as well as those with •pureŽ migraine or tension-type headaches. Cluster headache does not appear to respond as well to behavioral treatments. Data are less clear for headaches that are associated with menses. Headaches resulting from trauma require intensive, multi- component treatment. Patients with chronic daily or near daily, high intensity headache do not respond well to behavioral interven- tions alone (Blanchard, Appelbaum, Radnitz, Jaccard, & Dentinger, 1989). However, chronic daily headache has been found to be unrelated or positively related to the use of abortive and prophylactic medications (Holroyd et al., 1988). These data suggest that medications may be the “rst-line treatment for patients with chronic/daily or almost continu- ous headache. Age and Gender Young adults generally respond better to nonpharmaco- logical interventions than older adults and women generally respond better than men (Diamond, Medina, Diamond-Falk, & DeVeno, 1979; Diamond & Montrose, 1984). Geriatric headache patients have been found to be less responsive to standard behavioral treatment protocols (Holroyd & Penzien, 1986). When protocols are adjusted to compensate for any age-related declines in information processing capabilities, however, outcomes become much more favorable (e.g., Arena, Hannah, Bruno,&Meador, 1991;Arena,Hightower, & Chong, 1988; Nicholson & Blanchard, 1993). Behavioral treatments have been found to be especially effective for pediatric headache sufferers (Attanasio, Andrasik, Burke, Blake, Kabela, & McCarran, 1985; Hermann, Blanchard, & Flor, 1997; Hermann et al., 1995; Holden et al., 1999). Although no direct comparisons of child and adult headache patients have been conducted within a single study, a recent metaanalyzes, drawing on nearly 60 existing separate child and adult studies, revealed that children improved at a much greater level when treated in a similar fashion with either temperature or EMG biofeedback (Sara“no & Goehring, 2000). Treatment History Patients who have a history of habituation to medication, consume large amounts of medication, are suffering from drug-induced headaches, or are particularly refractory tend to respond less well to behavioral interventions (see earlier sec- tions). In these situations, detoxi“cation may need to be ac- complished before nonpharmacological intervention; some have suggested that nonpharmacological interventions be im- plemented during a gradual reduction and discontinuation of the offending medication in an effort to reduce the high dropout rates associated with drug withdrawal procedures (Gauthier et al., 1996; Grazzi et al., 2001). In these cases, pre- vious treatment provides clear contraindications for speci“c pharmacological interventions and begins to suggest alter- nate strategies that may be helpful to refractory patients. Blanchard, Andrasik, Neff, et al. (1982) examined a stepped-approach to treating diverse headache patients. Initially, all subjects (tension-type, migraine, or both com- bined) were treated with relaxation training, resulting in a substantial reduction in headache for all three headache types but particularly for tension-type headache sufferers. Those subjects who did not respond well to relaxation training were subsequently treated with biofeedback (thermal for pure mi- graine or combined headache; EMG for tension-type). The subsequent biofeedback treatment resulted in further signi“- cant reductions, particularly for combined headache patients. These “ndings suggest that relaxation training is useful for all three types of headaches but also emphasize the value of biofeedback for those who do not respond initially to relax- ation training (especially those with migraine or mixed headaches). These results further suggest that relaxation and Behavioral Treatment Planning 259 biofeedback may not work through a common mechanism, at least for a subset of patients. Comorbid Psychological Distress or Disorder The psychological status of the patient deserves special attention in order to identify conditions (mood and anxiety disorders, formal thought disorder, certain personality disor- ders) that might interfere with treatment and that need to be handled prior to or concurrent with treatment of the headache (see Holroyd, Lipchik, & Penzien, 1998; Lake, 2001; Merikangas & Stevens, 1997; Radat et al., 1999; see also the chapter by O•Callahan, Andrews, & Krantz in this volume; and the chapter by Jason & Taylor in this volume). These authors speculate that attention to comorbid conditions may be crucial to the success of both pharmacologic and nonphar- macologic therapies for certain patients. This conclusion is based on studies revealing the following: 1. The risk for major depression and anxiety disorders is higher for migraineurs than for nonmigraineous controls. 2. This in”uence is bi-directional. Migraine increases the risk of a subsequent episode of major depression (adjusted rel- ative risk ϭ 4.8), and major depression increases the risk of subsequent migraine (adjusted relative risk ϭ 3.3). 3. Comorbid anxiety and depression lead to increases in dis- ability and contribute to headaches becoming intractable. 4. Psychological distress is greater in headaches that are more frequent and chronic. 5. Depression is implicated in the transformation of episodic to chronic tension-type headache. 6. Certain personality disorders reveal a higher incidence of headache than otherwise would be expected. Further evidence for the importance of considering psy- chological factors is obtained from research that has attempted to identify variables associated with outcome. For example, studies have consistently shown that patients dis- playing only minor elevations on a scale commonly used to assess depression (Beck Depression Inventory) have a dimin- ished response to self-regulatory treatments (Blanchard et al., 1985; Jacob, Turner, Szekely, & Eidelman, 1983) and even abortive medication (Holroyd et al., 1988). Other variables (anxiety, scales 1, 2, and 3 of the MMPI) have been suggested as predictive of response to behavioral treatments as well (Blanchard et al., 1985; Werder, Sargent, & Coyne, 1981). Holroyd et al. (1988) found that patients who were high in trait anger, and to a lesser extent, depressive symptoms, were less likely to respond to abortive pharmacological agents for migraine headache but these variables were uncorrelated with response to a combination of relaxation training and thermal biofeedback, suggesting that the presence of the trait anger or depression could indicate nonpharmacological inter- ventions as a “rst line treatment. Jacob et al. (1983) found that headache patients without signi“cant depressive sypto- matology responded better to relaxation training than those with depressive symptomatology. These data suggest that a combination of pharmacological and nonpharmacological in- terventions may be useful, such as nonpharmacological man- agement of headache combined with pharmacological management of depression. CBT, which has received exten- sive support for treating anxiety and depression, may be more useful when comorbid conditions are present. Finally, signif- icant reductions in anxiety and depression typically occur following behavioral treatment, regardless of the headache type or the extent of headache relief (Blanchard et al., 1986; Blanchard, Steffek, Jaccard, & Nicholson, 1991). Environmental Factors It is also important to be mindful of environmental factors/ consequences that may be serving to maintainpain, as pointed out long ago by Fordyce (1976). Fowler (1975) has applied this perspective to headache patients. A patient is most likely to •learnŽ pain behavior when (a) pain behavior is posi- tively reinforced or rewarded, or (b) •wellŽ behavior is insuf- “ciently reinforced, punished, or aversive. Therapists can unwittingly become apartofthe learned painbehaviorprocess in several different ways. Attention from others is a near universal reinforcer; the sympathetic ear of a therapist can be especially powerful. Medication prescribingpracticescanfos- ter untoward learning effects as well. Palliative medications are often prescribed on an •as-neededŽbasis, accompanied by the caution, •Take this only when you really need it; it is pow- erful and may be addicting.ŽWhen instructed in this manner, many patients will delay taking the medication until their pain becomes barely tolerable or near maximum level. If the med- ication effectively relieves the headache, medication-taking behavior has become strongly reinforced and is likely to become more frequent in the future (based on principles of learning theory). Similar factors come into play when treating patients whose headache severity has markedly compromised their day-to-day functioning(acommon occurrence withpost- traumatic headache). Such patients are typically instructed, •Do only what you canŽor continue activities •until the pain becomes unbearable.ŽThe patient begins an activity, experi- ences increased pain, and then stops. Stopping the activity reduces discomfort and makes the patient less likely to engage in activity in the future. Consequently, therapists need to probe for environmental conditions, including familial 260 Headaches factors, which might be serving to maintain headache pain behavior and tobe aware ofhow he or she may subtly begin to contribute to the headache problem itself. When such environmental factors are in evidence, thera- pists are urged to lessen (gradually) attention given to pain symptoms, encourage and reinforce efforts to cope with head pain (ask, •How are you trying to manage your headaches?Ž rather than, •How is your headache today?Ž), encourage the inactive patient to set daily goals and stick to them despite the pain level, and arrange for needed anal- gesic medications to be taken on a time-contingent, as opposed to a pain-contingent, basis. Fordyce (1976) presents a detailed format for questions to ask of patients and family members being treated for chronic pain, which are also appropriate to consider when evaluating headache patients. In the only examination of its type, Allen and Shriver (1998) found that adding parent training in pain behavior management to standard biofeedback treatment signi“cantly incremented effectiveness over biofeedback alone for ado- lescent migraineurs. Patient Preference and Cost Effectiveness To date, there are no clear empirical data to suggest whether patient preference is predictive of treatment outcome. Nonetheless, this factor should always be considered when providing clinical treatments or interventions to individual patients. As a matter of course, compliance and cooperation are likely to be in”uenced by patient preference for treatment type; to ignore this would be a serious error. Treatment Algorithms Holroyd et al. (1998) provide treatment algorithms for the integration of behavioral and pharmacological therapies for recurrent migraine and tension-type headache that clinicians and researchers may “nd useful. While these algorithms have not been empirically tested, they are based on the extensive empirical literature previously described and represent a set of empirically supported decision-making guidelines. These authors suggest the use of both pharmacological and nonpharmacological treatments for migraines that are frequent and/or severe. For migraine headaches that are less frequent and unaccompanied by psychological prob- lems, factors such as patient preference, previous treatment experience/outcome, and cost may be used to select either pharmacological or nonpharmacological methods of treat- ment as a “rst line treatment. Should the initial choice fail to result in a satisfactory outcome, the alternate strategies may then be used as a supplement or second-line treatment. For tension-type headaches, Holroyd et al. (1998) con- sider behavioral interventions to be the treatment of choice. However, if the headaches are unremitting or complicated by signi“cant psychological disturbance, the use of antidepres- sant medication should be considered early. Minimal thera- pist contact interventions (see next) may be tried initially, with more intensive treatments applied if initial efforts are unsuccessful. If the addition of other behavioral and cognitive behavioral interventions fails to result in a satis- factory outcome, then prophylactic medications should be considered. Treatment Format and Delivery In addition to individual characteristics of patients that may predict response to treatment and aid in the selection of ap- propriate intervention(s),treatment planning also involves de- cisions about treatment format and delivery. Practical factors, such aslimited patientand/or therapist time, cost prohibitions, and limited geographical access, may preclude intensive indi- vidual therapies (Rowan & Andrasik, 1996). This has led researchers to explore more economical alternatives. Minimal Therapist Contact Interventions The main alternate delivery approach investigated to date re- tains a 1:1 focus, but markedly reduces clinician contact by supplementing treatment with instructional manuals and cas- settes that subjects utilize on their own at home or at work. The •prototypicalŽ minimal therapist contact intervention in- cludes an initial in-of“ce session, a mid-treatment of“ce ses- sion, and a “nal session with the therapist over the course of eight weeks or so, plus the use of two to three telephone con- tacts in between. These intermittent visits and calls are de- signed to keep patients engaged in treatment and to offset the high dropout rates that have occurred with entirely self-help approaches (Rowan & Andrasik, 1996). Thus, while time spent at the of“ce and with the therapist is signi“cantly re- duced (as are costs), time investments by the patient are still extensive. There is a substantial body of literature to suggest that non- pharmacological interventions may be effectively applied in cost-effective, minimal therapist contact formats and that these formats rival more •intensiveŽ interventions, with both adults andchildren (Haddocket al.,1997; Rowan&Andrasik, 1996). Furthermore, the bene“ts appear to be well maintained over time (Blanchard et al., 1988). Minimal therapist contact interventions have been found to have attrition rates similar to more intensive therapies and to produce two to six times more headache reduction per therapist hour than more intensive Summary and Future Directions 261 therapies (thus af“rming their cost-effectiveness). Factors that predict response to such minimal contact interventions are less clear than those that have been previously discussed for more •intensiveŽtreatments. Minimal therapist contact interventions have both advan- tages and disadvantages. Some of the advantages include reduced therapist time and costs to the patient, expanded accessibility of treatment, reduced scheduling demand, and reduced patient apprehension. Disadvantages include an in- crease in the time commitment and possibly a need for greater motivation on the part of the patient (Andrasik, 1996). Researchers have begunto explore thefeasibility of admin- istering behavioraltreatmentsto large numbers ofpatients, via mass media and the Internet. Researchers in the Netherlands (de Bruin-Kofman, van de Wiel, Groenman, Sorbi, & Klip, 1997) used television and radio instruction to supplement home-study material onheadache management. Favorablere- sults were obtained for the small sample (n ϭ 271) that was available to participate in the outcome analysis, however this was just a fraction of the people who purchased the self-help program (approximately 15,000). The “rst Internet-based study was centered at the worksite and was implemented via computer kiosks (Schneider, Furth, Blalock, & Sherrill, 1999). In the second study, patients accessed the Web from terminals at home (Ström, Pettersson, & Andersson, 2000). Modest improvements occurred, but attrition was consider- able (greater than 50%) in both investigations. Group Treatment Napier, Miller, and Andrasik (1997…1998),upon examining the limited investigations of behavioral and cognitive behav- ioral group interventions for recurrent headache, offered the following conclusions.Although onlyone studydirectly com- pared individual versus group delivery (Johnson & Thorn, 1989), the clinical outcomes for group treatment appeared to rival those reported for individually administered treatments. Subject retention rates were similar as well. Time devoted to group treatment varied considerably, ranging from a low of 270 minutes (or 4.5 hours) for a minimal contact approach to 900 minutes (or 15 hours) for an intensive, interdisciplinary approach. Group sizes ranged from 2 to 15 participants and utilized 1 to 2 therapists. The only study that directly investi- gated the role of therapist experience found it was signi“- cantly related to clinical outcome (Holroyd & Andrasik, 1978). These limited data suggest that group treatment is as effective as individual treatment for recurrent headache disor- ders. Once again, group treatment may be less expensive than individual therapy. However, group treatment also requires greater scheduling demands and may pose some of the same disadvantages as individual treatment, such as demands on patient and/or therapist time, cost prohibitions, and limited geographical access. SUMMARY AND FUTURE DIRECTIONS Individual studies, metaanalytic analyzes, and task force reviews have shown that a number of behavioral treatments (relaxation, biofeedback, and CBT) are ef“cacious for uncomplicated forms of migraine and tension-type headache, that improvement rates appear to rival those for pharmaco- logical treatments, and that certain treatment combinations can be more ef“cacious than single modality approaches. Researchers continue to explore the boundary dimensions for who is and who is not an ideal candidate for behavioral treat- ment. People experiencing cluster, menstrual, posttraumatic, drug-induced, or daily, unremitting headaches or certain comorbid conditions present special challenges that can require integrative, multidisciplinary, and intensive treatment approaches. Although much has been accomplished since behavioral researchers entered the headache arena approxi- mately 30 years ago, the battle has only begun. Much addi- tional research is needed, and we conclude the chapter with brief mention of likely directions this research will take. Researchers have just begun to realize the advantages of computers and the Web for facilitating both assessment and treatment. Pocket computers make it possible to monitor when ratings are actually made, administer prompts when data are incomplete, collect volumes of data in a relatively easy and ef- “cient manner, transmit data directly to the research/clinic site, and communicate interactively with the therapist or researcher (Holroyd, in press). Web- and CD-Rom-administered treat- ments have the potential to reach patients that heretofore could not or would not seek treatment. Folen, James, Earles, and Andrasik (2001) have shown that it is possible to use the Inter- net to transport biofeedback treatment to remote sites that lack the needed expertise. Particular challenges in these approaches will be ensuring adequate medical evaluation and follow-up, dealing with emergencies and crises, and resolving issues related to practicing across state-licensing boundaries. Although it is clear that certain behavioral treatments are ef“cacious, the mechanisms by which they operate are not well understood. This is not so surprising, considering that the etiologies of headache were not all that clear until re- cently. Accounts of pathophysiology for both of the major forms of headache have shifted from peripheral and vascular models to models that focus on central nervous system dys- function (central sensitization for tension-type headache and central excitability for migraine). Recognition of this will 262 Headaches certainly lead to development of new psychophysiological assessment approaches, investigation of biochemical changes that result from treatment (e.g., Olness, Hall, Rozneicki, Schmidt, & Theoharidies, 1999), and further development of treatments that are more directly tied to the underlying etiol- ogy (such as EEG biofeedback). Researchers are only beginning to address the all- important issues of treatment selection, treatment sequenc- ing, and patient selection. This is a daunting task that will require large samples and much effort. Most of the research to date has been conducted in specialized research or treat- ment centers, with patients who have been highly selected. The majority of patients who seek treatment are not seen in these settings. Importing treatments to the settings where they are most needed (primary care) and investigating para- meters for optimizing success will occupy much research time in the near term. Finally, it is expected that future re- search may identify certain headache types or situations that are uniquely suited for behavioral interventions, such as dur- ing pregnancy when women are advised to be very cautious about use of certain medications (e.g., Marcus, Scharff, & Turk, 1995). REFERENCES Allen, K. D., & Shriver, M. D. (1998). Role of parent-mediated pain behavior management strategies in biofeedback treatment of childhood migraines. Behavior Therapy, 29, 477…490. Andrasik, F. (1986). Relaxation and biofeedback for chronic headaches. In A. D. Holzman & D. C. Turk (Eds.), Pain man- agement: A handbook of psychological treatment approaches (pp. 213…329). New York: Pergamon Press. Andrasik, F. (1990). Psychologic and behavioral aspects of chronic headache. Neurologic Clinics, 8, 961…976. Andrasik, F. (1996). Behavioral management of migraine. Biomedi- cine and Pharmacotherapy, 50, 52…57. Andrasik, F. (2000). Biofeedback. In D. I. Mostofsky & D. H. Barlow (Eds.), The management of stress and anxiety in medical disorders (pp. 66…83). Boston: Allyn & Bacon. Andrasik, F. (2001a). Assessment of patients with headache. In D. C. Turk & R. Melzack (Eds.), Handbook of pain assessment (2nd ed., pp. 454…474). New York: Guilford Press. Andrasik, F. (2001b). Migraine and quality of life: Psychological considerations. Journal of Headache and Pain, 2(Suppl. 1), S1…S9. Andrasik, F., & Baskin, S. (1987). Headache. In R. L. Morrison & A. S. Bellack (Eds.), Medical factors and psychological disor- ders: A handbook for psychologists (pp. 325…349). New York: Plenum Press. Andrasik, F., Blanchard, E.B., Neff, D. F., & Rodichok,L. D. (1984). Biofeedback and relaxation training for chronic headache: A controlled comparison of booster treatments and regular contacts for long-term maintenance. Journal of Consulting and Clinical Psychology, 52, 609…615. Andrasik, F., Burke, E. J., Attanasio, V., & Rosenblum, E. L. (1985). Child, parent, and physician reports of a child•s headache pain: Relationships prior to and following treatment. Headaches, 25, 421…425. Andrasik, F., & Holroyd, K. A. (1980a). Reliability and concurrent validity of headache questionnaire data. Headache, 20, 44…46. Andrasik, F., & Holroyd, K. A. (1980b). A test of speci“c and non- speci“c effects in the biofeedback treatment of tension headache. Journal of Consulting and Clinical Psychology, 48, 575…586. Andrasik, F., & Wincze, J. P. (1994). Emotional and psychological aspects of mild head injury. Seminars in Neurology, 14, 60…66. Arena, J. G., Hannah, S. L., Bruno, G. M., & Meador, K. J. (1991). Electromyographic biofeedback training for tension headache in the elderly: A prospective study. Biofeedback and Self- Regulation, 16, 379…390. Arena, J. G., Hightower, N. E., & Chong, G. C. (1988). Relaxation therapy for tension headache in the elderly: A prospective study. Psychology and Aging, 3, 96…98. Attanasio, V., Andrasik, F., Burke, E. J., Blake, D. D., Kabela, E., & McCarran, M. S. (1985). Clinical issues in utilizing biofeedback with children. Clinical Biofeedback and Health, 8, 134…141. Barrett, E. J. (1996). Primary care for women: Assessment and man- agement of headache. Nurse Midwifery, 41, 117…124. Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disor- ders and phobias: A cognitive perspective. New York: Basic Books. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Benson, H., Klemchuk, H. P., & Graham, J. R. (1974). The useful- ness of the relaxation response in the therapy of headache. Headache, 14, 49…52. Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training. Champaign, IL: Research Press. Blanchard, E. B. (1992). Psychological treatment of benign headache disorders. Journal of Consulting and Clinical Psychol- ogy, 60, 537…551. Blanchard, E. B., & Andrasik, F. (1985). Management of chronic headaches: A psychological approach. New York: Pergamon Press. Blanchard, E. B., & Andrasik, F. (1987). Biofeedback treatment of vascular headache. In J. P. Hatch, J. G. Fisher, & J. D. Rugh (Eds.), Biofeedback: Studies in clinical efficacy (pp. 1…79). New York: Plenum Press. Blanchard, E. B., Andrasik, F., Ahles, T. A., Teders, S. J., & O•Keefe, D. (1980). Migraine and tension headache: A meta- analytic review. Behavior Therapy, 14, 613…631. References 263 Blanchard, E. B., Andrasik, F., Appelbaum, K. A., Evans, D. D., Jurish, S. E., Teders, S. J., et al. (1985). The ef“cacy and cost- effectiveness of minimal-therapist-contact, non-drug treatments of chronic migraine and tension headache. Headache, 25, 214…220. Blanchard, E. B., Andrasik, F., Appelbaum, K. A., Evans, D. D., Myers, P., & Barron, K. D. (1986). Three studies of psychologic changes in chronic headache patients associated with biofeedback and relaxation therapies. Psychosomatic Medicine, 48, 73…83. Blanchard, E. B., Andrasik, F., Jurish, S. E., & Teders, S. J. (1982). The treatment of cluster headache with relaxation and thermal biofeedback. Biofeedback and Self-Regulation, 7, 185…191. Blanchard, E. B., Andrasik, F., Neff, D. F., Arena, J. G., Ahles, T. A., Jurish, S. E., et al. (1982). Biofeedback and relaxation training with three kinds of headache: Treatment effects and their pre- diction. Journal of Consulting and Clinical Psychology, 50, 562…575. Blanchard, E. B., Appelbaum, K. A., Guarnieri, P., Morrill, B., & Dentinger, M. P. (1987). Five year prospective follow-up on the treatment of chronic headache with biofeedback and/or relax- ation. Headache, 27, 580…583. Blanchard, E. B., Appelbaum, K. A., Guarnieri, P., Neff, D. F., Andrasik F., Jaccard, J., et al. (1988). Two studies of the long- term follow-up of minimal therapist contact treatments of vascu- lar and tension headache. Journal of Consulting and Clinical Psychology, 56, 427…432. Blanchard, E. B., Appelbaum, K. A., Radnitz, C. L., Jaccard, J., & Dentinger, M. P. (1989). The refractory headache patient. I: Chronic daily, high intensity headache. Behaviour Research and Therapy, 27, 403…410. Blanchard, E. B., & Diamond, S. (1996). Psychological treatment of benign headache disorders. Professional Psychology: Research and Practice, 27, 541…547. Blanchard, E. B., Hillhouse, J., Appelbaum, K. A., & Jaccard, J. (1987). What is an adequate length of baseline in research and clinical practice with chronic headache? Biofeedback and Self- Regulation, 12, 323…329. Blanchard, E. B., Nicholson, N. L., Radnitz, C. L., Steffek, B. D., Appelbaum, K. A., & Dentinger, M. P. (1991). The role of home practice in thermal biofeedback. Journal of Consulting and Clin- ical Psychology, 59, 507…512. Blanchard, E. B., Nicholson, N. L., Taylor, A. E., Steffek, B. D., Radnitz, C. L., & Appelbaum, K. A. (1991). The role of regular home practice in the relaxation treatment of tension headache. Journal of Consulting and Clinical Psychology, 59, 467…470. Blanchard, E. B., & Schwarz, S. P. (1988). Clinically signi“cant changes in behavioral medicine. Behavioral Assessment, 10, 171…188. Blanchard, E. B., Steffek, B. D., Jaccard, J., & Nicholson, N. L. (1991). Psychological changes accompanying non- pharmacological treatment of chronic headache: The effects of outcome. Headache, 31, 249…254. Blanchard, E. B., Taylor, A. E., & Dentinger, M. P. (1992). Prelimi- nary results from the self-regulatory treatment of high medica- tion consumption headache. Biofeedback and Self-Regulation, 17, 179…202. Bogaards, M. C., & ter Kuile, M. M. (1994). Treatment of recurrent tension headache: A Meta-analytic review. Clinical Journal of Pain, 10, 174…190. Borgeat, F., Hade, B., Larouche, L. N., & Bedwani, C. N. (1980). Effects of therapist active presence on EMG biofeedback train- ing of headache patients. Biofeedback and Self-Regulation, 5, 275…282. Budzynski, T. H., Stoyva, J. M., Adler, C. S., & Mullaney, D. J. (1973). EMG biofeedback and tension headache: A controlled outcome study. Psychosomatic Medicine, 35, 484…496. Cahn, T., & Cram, J. R. (1980). Changing measurement instrument at follow-up: A potential source of error. Biofeedback and Self- Regulation, 5, 265…273. Campbell, J. K., Penzien, D. B., & Wall, E. M. (2000). Evidence- based guidelines for migraine headaches: Behavioral and phys- ical treatments. Retrieved October 2000, from www.aan.com/ public/practiceguidelines/headache_g1.htm Cohen, M. J., McArthur, D. L., & Rickles, W. H. (1980). Compari- son of four biofeedback treatments for migraine headache: Phys- iological and headache variables. Psychosomatic Medicine, 42, 463…480. Collins, F. L., & Thompson, J. K. (1979). Reliability and standard- ization in the assessment of self-reported headache pain. Journal of Behavioral Assessment, 1, 73…86. Cox, D. J., Freundlich, A., & Meyer, R. G. (1975). Differential effectiveness of electromyograph feedback, verbal relaxation instructions, and medication placebo with tension headaches. Journal of Consulting and Clinical Psychology, 43, 892…898. de Bruin-Kofman, A. T., van de Wiel, H., Groenman, N. H., Sorbi, M. J., & Klip, E. (1997). Effects of a mass media behavioral treatment for chronic headache: A pilot study. Headache, 37, 415…420. Diamond, S., Medina, J., Diamond-Falk, J., & DeVeno, T. (1979). The value of biofeedback in the treatment of chronic headache: A “ve-year retrospective study. Headache, 19, 90…96. Diamond, S., & Montrose, D. (1984). The value of biofeedback in the treatment of chronic headache: A four-year retrospective study. Headache, 24, 5…18. Diener, H. C., & Wilkinson, M. (Eds.). (1988). Drug-induced headache. Berlin, Germany: Springer-Verlag. Duckro, P. N., Tait, R., Margolis, R. B., & Silvermintz, S. (1985). Behavioral treatment of headache following occupational trauma. Headache, 25, 328…331. Epstein, L. H., & Abel, G. G. (1977). An analysis of biofeedback training effects for tension headache patients. Behavior Therapy, 8, 37…47. Evans, R. W. (2001). Diagnostic testing for headache. Medical Clin- ics of North America, 85, 865…886. [...]... quality of life Journal of Consulting and Clinical Psychology, 60, 55 2 56 8 Anderson, B L (1994) Surviving cancer Cancer Supplement, 74, 1484…1494 Anderson, B L., Woods, X A., & Copeland, L J (1997) Sexual self-schema and sexual morbidity among gynecologic cancer survivors Journal of Consulting and Clinical Psychology, 65, 221…229 Andrykowski, M A., Redd, W H., & Hat“eld, A K (19 85) Development of anticipatory... W (2001) Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination Journal of the American Medical Association, 2 85, 2208…22 15 Holroyd, K A., & Penzien, D B (1986) Client variables and the behavioral treatment of recurrent tension headache: A meta-analytic review Journal of Behavioral Medicine, 9, 51 5… 53 6 Hermann, C., Kim,... Physiopathological and clinical concepts Advances in neurology (Vol 33, pp 3 35 341) New York: Raven Press Lake, A E., IV (2001) Behavioral and nonpharmacological treatments of headache Medical Clinics of North America, 85, 1 055 …10 75 2 65 Mathew, N T., & Bendtsen, L (2000) Prophylactic pharmacotherapy of tension-type headache In J Olesen, P Tfelt-Hansen, & K M A Welch (Eds.), The headaches (2nd ed., pp 667…673)... Turk, D C (19 95) Nonpharmacological management of headache during pregnancy Psychosomatic Medicine, 57 , 52 7 53 5 Nicholson, N L., & Blanchard, E B (1993) A controlled evaluation of behavioral treatment of chronic headache in the elderly Behavior Therapy, 24, 3 95 408 Martin, P R (1993) Psychological management of chronic headaches New York: Guilford Press Olesen, J (2000) Classi“cation of headache In... Safety and rational use of the triptans Medical Clinics of North America, 85, 959 …970 ter Kuile, M M., Spinhoven, P., Linssen, A C G., & van Houwelingen, H C (19 95) Cognitive coping and appraisal processes in the treatment of chronic headaches Pain, 64, 257 …264 Tfelt-Hansen, P., & Welch, K M A (2000a) General principles of pharmacological treatment of migraine In J Olesen, P Tfelt-Hansen, & K M A Welch... of control or death while under anesthesia, fears of being partially awake during surgery, and fears of damage to body parts There are often psychological reactions related to the site of surgery or to the loss of a particular function, such as bowel function as a result of a colostomy Often these negative emotional reactions arise from the signi“cance of the loss, especially when involving the face,... meta-analysis of controlled trials Cephalalgia, 17, 113…18 1 Hermann, C., Blanchard, E B., & Flor, H (1997) Biofeedback treatment for pediatric migraine: Prediction of treatment outcome Journal of Consulting and Clinical Psychology, 65, 611…616 Holroyd, K A., France, J L., Cordingley, G E., Rokicki, L A., Kvaal, S A., Lipchik, G L., et al (19 95) Enhancing the effectiveness of relaxation-thermal biofeedback... E., & Snarr, C (1986) Biobehavioral a treatment of essential hypertension: A group outcome study Biofeedback and Self-Regulation, 11, 257 …277 Holroyd, K A., & Andrasik, F (1978) Coping and the self-control of chronic tension headache Journal of Consulting and Clinical Psychology, 46, 1036…10 45 Folen, R A., James, L C., Earles, J E., & Andrasik, F (2001) Biofeedback via telehealth: A new frontier for applied... References biofeedback training: Cognitive changes underlying improvements in tension headache Journal of Consulting and Clinical Psychology, 52 , 1039…1 053 Horton, B T., & Macy, D., Jr (1946) Treatment of headache Medical Clinics of North America, 30, 811…831 International Headache Society (1999a) Guidelines for controlled trials of drugs in migraine In P Tfelt-Hansen (Chair), Members handbook 2000... followed a group of cancer patients for a period of eight months, at the end of which one-third had died Beyond site of cancer and levels of symptoms at baseline, a measure of pessimism obtained earlier signi“cantly predicted mortality rates, that is, people with a pessimistic orientation were less likely to be alive at the eight-month follow-up Social Support The difference in the level of social support . in- cludes an initial in -of ce session, a mid-treatment of ce ses- sion, and a “nal session with the therapist over the course of eight weeks or so, plus the use of two to three telephone con- tacts. Holroyd, K. A. (1980b). A test of speci“c and non- speci“c effects in the biofeedback treatment of tension headache. Journal of Consulting and Clinical Psychology, 48, 57 5 58 6. Andrasik, F., &. al. (1982). Biofeedback and relaxation training with three kinds of headache: Treatment effects and their pre- diction. Journal of Consulting and Clinical Psychology, 50 , 56 2 57 5. Blanchard,