“Why, then, ‘tis none to you, for there is nothing either good or bad, but thinking makes it so“-Shakespeare’s Hamlet
HEADACHES, STRESS AND NEGATIVE EMOTIONS
THEIR RELATIONSHIP IN A CBT MODEL
1. STRESS & NEGATIVE EMOTIONS are the most common triggers for headache.
2. They also set up a vicious cycle with HEADACHE
STRESS & NEGATIVE EMOTIONS ⇔ HEADACHE
Because of this vicious cycle can be likened to that of a chicken and the egg scenario.
Which means, we can intervene at breaking this vicious cycle at the “chicken” level (STRESS & NEGATIVE EMOTIONS) or the “egg” level (HEADACHE)
SO, LET’S TALK ABOUT STRESS…
Stress is a condition or feeling experienced when a person perceives that “demands exceed the personal and social resources the individual is able to mobilize.”
Different people have different thresholds for stress
STRESS = PERCEIVED Demands – PERCEIVED Personal & Social Resources
- Things that are high demand are not necessarily stressful if someone believes they have the resources at their disposal to cope with the same
- Some demands are universally high that almost everyone perceives them as such (world trade center, divorce, etc.)
NOTICE THAT OUR LEVEL OF STRESS DEPENDS ON “PERCEPTION”…
THINKING IS AN IMPORTANT INTERMEDIATE STEP BETWEEN OUR SITUATION AND OUR STRESS LEVEL
1) Reducing Perceived Demands
- we can reduce how much we demand of ourselves
- we can reduce how we perceive the demands on ourselves
2) Increasing Perceived Personal & Social Resources
- we can increase our resources to deal with what’s on our plate
- we can increase our perception of how our resources can be leveraged to help us deal with the demands we face
The way we feel is correlated with the way we think
We have discussed this connection in greater detail in another article title Cognitive Behavioural Therapy.
Emotions give direction to our thoughts
- Anger tends to bias people towards noticing ways they have been hurt
- Depression tends to bias people towards noticing negative aspects of their lives
- Anxiety tends to bias people towards noticing danger latent in many things
There is some truth to our observations obviously, but…
- When we feel more intense moods, we are likely to distort, discount or disregard information that contradicts the validity of our moods and beliefs
- The stronger the mood, the more extreme the thinking
- The premise to CBT is that it is favourable to our mood and behaviours to right-size our perceptions and evaluations
What’s the difference between a fire?
And a fire with fuel around?
Primary (Hard-wired) emotions
- anger, disgust, fear, happiness, sadness and surprise
- these are emotions that babies can experience as they are facilitated by the limbic system (an old part of the brain) and don’t require active input from the frontal lobes (the thinking part of the brain, i.e., “what do you think he meant by that?”, “I feel bad I’m keeping my mom up at night”, etc.)
Secondary (Manufactured) emotions
- Guilt, shame, embarrassment, self-criticism
- These require thoughts from our frontal lobe to keep the fire of these emotions (i.e., guilt, shame, embarrassment, self-criticism) burning on and on and on
- How we view events (i.e., our thinking) can greatly modify how gripping these emotions are over us, and what we do
- These have been discussed in greater detail in our article titled Cognitive Behavioural Therapy
- Refers to the exact words/thoughts you say to yourself during a specific situation or emotional state
- e.g., “oh no, not another headache” upon starting to feel pain and irritability
- e.g., “I’m going to get a headache” upon seeing a well lit room walking into the doctor’s office.
- These have been discussed in greater detail in our article titled Cognitive Behavioural Therapy
- more deep-seated views you have of yourself, and of your relationship to others and the world in general
- “The last thing a fish notices is water” is a saying that applies to Core beliefs as they often escape our conscious notice as they are generalized rules that may never have been formulated
- They need to be inferred from our attitudes, rules and assumptions, rather than observed
- e.g., The core belief that one is incompetent may mascaraed in their day-to-day in the form of:
- Attitude: “It’s terrible to fail.”
- Rule: “I should give up if a challenge seems too great.”
- Assumptions: “If I try to do something difficult, I’ll fail. If I avoid doing it, I’ll be okay.”
Relationship between Automatic thoughts and Core beliefs
- These are related, and has been discussed in our article on CBT
- But to give some examples:
- The Automatic thought “I have let down my company by losing that contract” may be based on the Rule that “I must never make a mistake”
- “as I don’t get along with Joe, I will never be a successful member of the team” may be based on the Rule that “I must be liked by everyone”
“What gets us into trouble is not what we don’t know. It’s what we know for sure that just ain’t so.”
– Mark Twain
If we right-size our Automatic Thoughts and Core Beliefs as they relate to STRESS & NEGATIVE EMOTIONS, AND AS THEY RELATED TO HEADACHE (and factors associated to headache like concerns about medication, disability, etc.) so that they are less
We will have reduced the headache pain experience, at a neurophysiological level.
That is, we aren’t just “fooling” or “brainwashing” ourselves.
“REPEAT A LIE OFTEN ENOUGH AND IT BECOMES THE TRUTH”
-LAW OF PROPAGANDA (ILLUSION OF TRUTH EFFECT) OFTEN ATTRIBUTED TO THE NAZI JOSEPH GOEBBELS
We have discussed common things (i.e., cognitive distortions) we think or tell ourselves that just ain’t so in our article on Language & Recovery.
Some of the most common cognitive distortions we see in the way people with chronic headaches relate to the world are as follows:
1. Exaggerating demands of the situation
- e.g., “this headache will make it impossible for me to get anything done.”
2. Minimize the available psychosocial resources
- e.g., “I cannot do anything to influence this headache”, “no one can help me”
- e.g., “these headaches will result in my losing my job”
AWARENESS OF OUR INNER DIALOGUE
IN THE CONTEXT OF CHRONIC HEADACHES
“When you change the way you look at things, the things you look at change.”
– Wayne Dyer
Socratic Dialogue, also known as Socratic Questioning, is a useful method of discussion/reflection to shift our attention to a more conscious – less habitual way – of noticing things.
We have discussed this in greater detail in our article on Socratic Dialogue.
When Venice started to decline because the sea route became an issue…
they appointed an autocratic leader
We prefer simple solutions
1. They can be extreme
- e.g., “you are my sunshine, my only sunshine”
2. They can be pervasive
- e.g., putting all eggs in one basket
3. Tip offs
- e.g., “I wish…, If only…, as soon as…, I can’t until…, I would expect…”
4. Common subtypes (Angermeyer et al. 2011)
5. Can make us very passive when it comes to mood, i.e., waiting for the spirits to move us.
- e.g., “there’s not point trying, this headache makes me a write-off”
- What would you tell someone you love in this situation?
- You have to do things even if you don’t feel like doing them (discussed more in our article on Scheduling & Behavioural Activation)
We have discussed this in our article on Language & Recovery.
WHEN SOMEONE CLOSE TO YOU STARTS ASKING YOU QUESTIONS, YOU OFTEN KNOW WHERE THEY’RE GOING WITH THEIR QUESTIONS.
- Like that, if you were to ask yourself questions, how do you remove your own bias?
- How do you ask the questions in a way where you ‘don’t see yourself coming’?
- That is, it’s pretty likely that your going to ask yourself questions to get to the answer that (you think) “you already know”.
We have discussed this in our article on Socratic Dialogue.
CHANGING YOUR EXPERIENCE OF LIFE
WHERE HEADACHE CURRENTLY EXISTS TOO
So, once we have identified Maladaptive thoughts related to stress, negative emotions and headaches, what do we do about them?
We evaluate them for validity/usefulness using a MALADAPTIVE THOUGHTS RECORD.
Research has shown that it takes between 30-40 THOUGHT RECORDS to make it an automatic process that happens quickly (seconds to minutes) whereas the first THOUGHT RECORDS may take an hour each.
This involves our ability to:
- Think critically
- Be aware of the language we use, even when thinking
- Our skills in debate/rhetoric (this is the art from which Socratic Dialogue was borne)
We have discussed this above in other sections
- “Socratic Dialogue“
- “Strategies in re-evaluating your beliefs in a way that lines up with your desired outcome“
But some useful questions to ask in the Chronic Headaches, Stress & Negative Emotion paradigm are:
1. What is the evidence for my thought?
2. What alternative views are there?
3. What are the advantages and disadvantages to this way of thinking?
4. What logical errors am I making?
Behavioural Experiments are set up so test hypotheses.
The things we tell ourselves – Automatic thoughts and Core beliefs – are in fact hypotheses.
When we set up a Behavioural experiment, we have to make it clear what it is exactly we will do, and also strategize so as to maximize the chances of a getting a positive outcome.
Let’s take an example of a patient who believes that her husband is not supportive.
- E.g., “If I ask my husband to help prepare the meal he will refuse and be nasty to me”
- This is simply the patient’s AUTOMATIC THOUGHT in the situation where she would like to ask her husband for help.
- E.g., “how has he behaved previously in similar situations?”
- This is a review of the evidence for and against a HOT THOUGHT (see Maladaptive thoughts record for the context).
- E.g., how a patient asked her husband for help would be considered in detail, with role playing a possible option
- You wouldn’t expect a sports team to run the experiment “we can beat the other team” without preparing?
- Likewise, when we set up a Behavioural experiment, we have to make it clear what it is exactly we will do, and also strategize so as to maximize the chances of a getting a positive outcome.
- In this case, this may involve practising assertiveness with role-playing.
- Did they reinforce or weaken maladaptive thought?
- If the experiment went in the way you were hoping, you will find your old way of thinking starting to weaken
- If the experiment went against the way you were hoping (i.e., it reinforced your fears or your negative thoughts)
- What went wrong?
- Was the experiment effectively sabotaged by further maladaptive thoughts?
- e.g., I’m not good at learning things so this assertiveness practice is not going to work
- it may be helpful to formulate a new rule li
- E.g., “don’t make assumptions about how other people will react, rather, take steps and find out”
The most common negative Core beliefs in medical illness/injury are:
- E.g., “Who would love me?”
- E.g., “I have no control over my life”
- E.g., “I can’t do anything right”
There are some strategies in helping you identify negative Core beliefs:
- You may have some repetitive assumptions, rules or attitudes that show up in different contexts
- E.g., “I am inadequate unless I succeed”
2. Logical Errors
- E.g., “I’m a hopeless mother because my headaches have stopped my taking part in my children’s school activities”
- This may stem from the maladaptive belief may be “health problems shouldn’t interfere with any of one’s roles or responsibilities.”
- Black & white thinking/dichotomous reasoning (See Language & Recovery for other logical fallacies)
3. Global Evaluation
- E.g., “I’m weak”
- This may stem from the maladaptive belief may be “I need to be strong always”
- Labelling (See Language & Recovery for other logical fallacies)
4. Early Memories
- E.g., Beliefs concerning the need to comply with all requests made of them may recall childhood experiences in which this belief was reinforced by statements to the effect that if they didn’t do what the were told, some dire consequences would follow
5. Excessive Emotions
- E.g., belief that it’s necessary always to be in control will be devastated (rather than distressed) when a headache results in their having to cancel an appointment
- Emotional reasoning (See Language & Recovery for other logical fallacies)
6. Downward Arrow
- When evaluating automatic thoughts in the usual way, rather than challenging the automatic thoughts, you ask:
- “Supposing that was true, what would that mean to me?”
- And to the answer to that, you ask, “Supposing that was true, what would that mean to me?”
- You keep asking this in response to your answers until you come up with a statement that is general enough to encompass not only the original problem situation but also other situations in which the same rule is operating.
It’s not what you say…
It’s how you say it
It is more challenging to be aware of non-verbal communication you have with yourself…
- They say 80% of communication is non-verbal
What are you saying to yourself?
- This is a big topic and involves metacognitive ability
- We discuss this in even more detail in our article Language & Recovery
- Mindfulness helps to start noticing the answer to this question
- Education will help you recognize subtle ways you redirect your attention towards your biases
- We will discuss some other specific ways on how to deal with negative Core Beliefs in the next two sections.
Once you have identified negative Core Beliefs, then what?
You can perform some Behavioural Experiments to test for other possibilities…and to test for alternative Core Beliefs by:
1. Gathering evidence about other peoples’ standards rather than assuming one’s own are universal
2. Observing what others (as a reflection of their different standards)
3. Acting contrary to the assumptions and observing the consequences
- E.g., If you see yourself that you are helpless and unlovable, you may think of helping a new immigrant with their CV to see what happens?
4. Testing a new rule (in keeping with a desired Core Belief) in action
- This is often the most effective way of dealing with negative Core Beliefs
- Often, this will be a Core Belief that you desire
- Often, it’s the opposite of an identified negative Core Belief
- It helps you develop confidence by doing, not thinking
- I’m unacceptable and unimportant
- It is unacceptable if others are upset with me
- Conflict is my fault
Envisioned new CB
- My needs are also important
- Conflict is normal in relationships, because different people often want different things
- If I stand up for myself and tolerate my discomfort, I’ll be better in the long run.
- I will pay attention to what I want and speak up for myself.
- When I disagree with someone, I will express my point of view. I will tolerate my discomfort and not compromise with someone else just to avoid conflict.
- I will spend some time every day doing something for myself that is important to me.
Verbally/Cognitively challenging the way you see things (i.e., negative Core Beliefs) is another approach albeit, on average considered to be less effective than the Behavioural Experiment approach mentioned in the previous section.
- Negative Core Beliefs are like weeds in your lawn.
- Positive Core Beliefs are like nice thick green lawn.
- Verbally/Cognitively challenging negative Core Beliefs is like pulling the weeds.
- Behavioural experiments to strengthen positive Core Beliefs is like nurturing your lawn to “crowd out” the weeds, so there is no room for them to fluorish.
The kinds of questions you can ask yourself to verbally/cognitively challenge Core Beliefs
1. In what way is this belief unreasonable?
- E.g., “I should always be strong” ignores human frailty
2. In what way is the belief unhelpful?
- Perfectionists often defend the beliefs, but what about the opportunity cost (i.e., extra time for relatively small gains; the associated anxiety; the increased likelihood of avoiding opportunities because of fear of losing time, failure, anxiety, etc.)
3. Where did the belief come from?
- Keep in mind that one can fall into ruminating about this. Consider scheduling “Thinking through time“
- Use strategies to “create distance”/foster metacognition
4.What would be a more moderate alternative belief that would confer the advantages of the maladaptive belief without its disadvantages?
Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. Br J Psychiatry. 2011;199(5):367-372. doi:10.1192/bjp.bp.110.085563
Beck, J. S. Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press (2011).
Burns, D. D. When Panic Attacks. New York: Morgan Road Books (2006).
Greenberger, D. & Padesky, C. Mind Over Mood, 2nd Edition. Guilford (2015).
Martin, P. (1993). Psychological Management of Chronic Headaches: Treatment Manual for Practitioners. Guilford Press.
Writing: Dr. Taher Chugh
Last update: March 2021