Testing the impact of anger awareness and expression training and relaxation training on chronic headaches

Chronic headache is a serious and common problem (World Health Organization [WHO], 2004). There is a heavy social and economic burden associated with chronic headaches. Relaxation training, which is thought to work by decreasing arousal/anxiety, is a commonly used behavioral treatment for chronic headache and has been shown to be effective. However, other research has suggested that anger may be an important emotion in the experience of pain, and that suppression of anger may lead to worse pain (Quartana et al., 2006). Although existing literature has demonstrated that anger suppression leads to worse pain, it has not addressed the question of whether teaching someone to express anger appropriately leads to decreases in pain. In this study, we tested a new intervention, Anger Awareness and Expression training (AAET), which focused on teaching participants to recognize their anger and express it appropriately. In this study, 130 undergraduate students with chronic headaches were randomized to three different conditions - Relaxation training (RT), Anger Awareness and Expression training (AAET), or an assessment-only control group. Both RT and AAET were implemented in a small-group setting over three weekly, one-hour long sessions. Participants completed self-report measures of psychological functioning, headache management self-efficacy, and headache frequency, severity, duration, and disability, at baseline and 6-week follow-up. Active group participants also completed measures of affect and pain pre- and post-session. Analyses of in-session process variables showed that the two interventions worked differently, with RT decreasing negative mood, arousal, and pain post-session, and AAET increasing arousal post-session. However, both led to significant improvement in headaches at follow-up, and largely did not differ from each other in their effects. Both led to significant decreases in headache frequency, duration, and disability, and increases in headache management self-efficacy. This study shows that a brief group-based intervention focusing on anger expression is an effective alternative to relaxation training for individuals with chronic headaches. Future research should focus on understanding whether there are similar or different processes underlying these two interventions, and the types of patients who will benefit the most from each intervention

Effects of Anger Awareness and Expression Training versus Relaxation Training on Headaches: A Randomized Trial

Background and purpose: Stress contributes to headaches, and effective interventions for headaches routinely include relaxation training (RT) to directly reduce negative emotions and arousal. Yet, suppressing negative emotions, particularly anger, appears to augment pain, and experimental studies suggest that expressing anger may reduce pain. Therefore, we developed and tested anger awareness and expression training (AAET) on people with headaches. Methods: Young adults with headaches (N = 147) were randomized to AAET, RT, or a wait-list control. We assessed affect during sessions, and process and outcome variables at baseline and 4 weeks after treatment. Results: On process measures, both interventions increased self-efficacy to manage headaches, but only AAET reduced alexithymia and increased emotional processing and assertiveness. Yet, both interventions were equally effective at improving headache outcomes relative to controls. Conclusions: Enhancing anger awareness and expression may improve chronic headaches, although not more than RT. Researchers should study which patients are most likely to benefit from an emotional expression or emotional reduction approach to chronic pain