Journal of Psychosomatic Research 66 (2009) 465–470

Headache sufferers' drawings reflect distress, disabilityand illness perceptions

Elizabeth Broadbenta,⁎, Kate Niederhofferb, Tiffany Haguec, Arden Cortera, Lisa Reynoldsa

aDepartment of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New ZealandbThe University of Texas, Austin, TX, USAcDartmouth College, Hanover, NH, USA

Received 15 February 2008

Abstract

Objective: Drawings have recently been used with patientswith heart problems to assess their perceptions of their illness.This study aimed to investigate whether drawings could be auseful way to assess headache patients' perceptions of theirheadaches and their reactions. Methods: In a cross-sectionalstudy, 65 university students who experienced persistent head-aches were asked to draw a picture of how their headachesusually affected them. Drawings were assessed in three ways:they were categorized based on content; their size was measured;and image analysis software assessed their darkness. Associationsbetween drawings, illness perceptions, mood, and health out-comes were assessed. Results: Twenty-seven people drew anexternal force to the head and these people had greater ratings ofaverage pain and were more likely to attribute their headache to

⁎ Corresponding author. Department of Psychological Medicine,Faculty of Medical and Health Sciences, The University of Auckland,Private Bag 92019, Auckland, New Zealand. Tel.: +64 9 373 7599x86756;fax: +64 9 373 7013.

E-mail address: e.broadbent@auckland.ac.nz (E. Broadbent).URL:

http://www.fmhs.auckland.ac.nz/som/staffct/staff_details.aspx?staffID=6562726F303332.

0022-3999/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1016/j.jpsychores.2008.09.006

stress. Darker drawings were associated with greater emotionaldistress and lower vitality. Larger drawing size was associatedwith perceptions of worse consequences, worse symptoms, worseemotional representations, lower vitality, higher pain, and moredays of restricted activity, lower happiness, and higher sadness.Conclusion: Drawings offer an additional way to assess peoples'experience of their headaches and reflect illness perceptions anddistress. People draw how they see themselves experiencing theirheadache and often include expressions and reactions. Theinclusion of force to the head, darker drawings, and largerdrawings are associated with worse perceptions of the headacheand higher pain. Drawings may be a useful way for clinicians tounderstand patients' experience of pain.© 2009 Elsevier Inc. All rights reserved.

Keywords: Drawings; Headache; Illness perceptions; Pain

Introduction

Recent work has shown that patients' drawings of theirillness can reveal their perceptions about the physiologyand nature of their illness. Myocardial infarction patients'

drawings of their heart captured the extent to which theybelieved their heart had been damaged, which predictedspeed of return to work and self-reported recovery [1].Furthermore, patients whose drawings of their heartincreased in size over the recovery period reported greateranxiety and poorer recovery at follow-up than those whosedrawings got smaller [2], suggesting that drawing sizecan indicate the extent to which the patient is thinkingabout the illness. This is supported by other research thathas shown that larger sizes of heart failure patients'drawings of their heart are associated with higher levels ofcardiac anxiety [3].

Using drawings as a technique to assess patients'perceptions of an illness relies on patients' abilities to

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visualize the affected organ. The heart is a well-known partof the body and more easily drawn than more obtuse organssuch as the pancreas or spleen. In this study, we wereinterested in whether drawing could be a useful method toassess perceptions in another part of the body, the head.

Headaches are commonly experienced in the generalpopulation, with about 30% of the Western populationexperiencing at least one headache per year [4]. Annuallyin the UK, about 3 million days are taken off work due toheadache. Research has shown that patients' illnessperceptions are important in headache patients. Headachepatients who believe that their condition will last a longtime and that it has severe personal consequences are morelikely to be depressed [5]. The most common attributionsfor chronic daily headache are psychological, such as stressor overwork.

Previous work with children suggests that drawings maybe a useful way to assess perceptions in headache patients.Unruh et al. [6] asked children to draw their pain. Thematicanalysis revealed themes including actions and instrumentscausing pain, personification of the pain, physiologicalrepresentation of the pain, perceptual disturbance associatedwith the pain, abstract representation of the pain, andlocation of the pain. The content of children's headachedrawings can reliably differentiate migraine from non-migraine headaches, and changes in drawings over timereflect clinical improvements [7,8]. Children who havemigraines tend to include sharp objects, while those withtension-type headaches include compression, and thosewith somatoform disorders sometimes include whirls inthe head [9].

Chronic pain patients are often asked to draw the locationof their pain onto provided outlines of the body, and thesedrawings can indicate unusual diseases or show changes inexperienced pain over time [10]. Asking patients to drawmore general pictures of how they experience their pain(without any outlines) may reveal additional informationabout the patients' perceptions.

In this study, we aimed to investigate adults' perceptionsof their headaches using drawings as an assessment method.We were interested in studying how features of the drawingswere associated with individuals' illness perceptions, levelsof pain, disability, and number of doctor visits. From ourprevious work, we hypothesized that bigger drawings wouldbe associated with poorer illness perceptions and poorerphysical and mental functioning.

Method

This cross-sectional study was conducted at the Uni-versity of Texas, Austin. Sixty-five introductory psychologystudents were recruited for the study by online invitation.The only restrictive criteria were that the student had toexperience persistent headaches. The study was approved bythe Institutional Review Board.

Participants were asked to draw their headache as it mostcommonly affected them. The instructions were adaptedfrom previous studies with heart attack patients and read,“While many patients suffer from headaches, headaches arerarely experienced by different people in the same way—inlocation, intensity and the nature of the pain. As a result,people picture their headache in different ways. In thisproject, we are interested in the way you see your headache.We would like you to draw your image of your headache. Weare not interested in your drawing ability—a simple sketch isfine. We are interested in how you see your headache. In thespace below, please draw your headache as it mostcommonly affects you.” These instructions were printed onan otherwise blank A4 size piece of paper as part of a largerquestionnaire. Participants completed the form with aballpoint pen.

The questionnaire included the Brief Illness PerceptionQuestionnaire (Brief IPQ) [11], a nine-item scale thatassesses participants' views of the timeline, consequences,causes, symptoms, personal control, helpfulness of treat-ment, concern, emotional reactions, and understanding oftheir headaches. The vitality and mental health scales of theSF36 were included [12]. The questionnaire also includedtwo questions asking participants to rate the worst pain andaverage pain from their headaches on scales from 1 (no pain)to 10 (extreme pain). Participants reported the number ofdoctor visits they had made in the past year, as well as thenumber of days in the past month they restricted theiractivities due to headaches.

The drawings were analysed by laying out all the picturesand identifying common aspects of the drawings thatdifferentiated between them. The four raters were healthpsychology academic staff and postgraduate students. Theseaspects were recorded and the drawings were subsequentlyscored along these dimensions. Scoring was performed as acollective group process with high agreement within thegroup; κ statistic was not calculated. Similar to previouswork, we measured the size of the drawings in millimetresfrom top to bottom and from side to side [2,3].

Statistical analyses

Previous research with heart attack patients foundcorrelations between drawings and illness perceptionsranging between r=.33 and r=.45. A two-tailed poweranalysis with r=.35, α=.05, and power=.80 showed that61 participants were required [13].

Data were analysed using SPSS (version 14). Thenormality of the data was checked using Kolmogorov–Smirnov tests, and nonparametric statistics were used wheredata were not normally distributed. Vertical and horizontalsize of drawings, control, identity, vitality, and mental healthwere normally distributed, and Pearson's r was used forcorrelations between these items; in all other correlations,Spearman's ρ was used. Differences between groups wereanalysed using Mann–Whitney and Kruskal–Wallis tests.

467E. Broadbent et al. / Journal of Psychosomatic Research 66 (2009) 465–470

Results

What did patients draw?

Some examples of headache drawings are shown in Fig. 1.From visual inspection, a number of differences could beidentified between patients' drawings. First, there weredifferences in the location of pain drawn in the head (e.g.,in the temples or the back of the head) and in the number ofplaces pain was drawn. Second, drawings differed in thenature of the pain drawn; there was a large group of peoplewho drew their pain as an external force on their head, such asa hammer or dagger, while others drew their pain as anentirely internal process within the head, such as a simpleshaded area. Third, patients differed in the intensity of thedrawings of pain; some patients used thick heavy pen strokes

Fig. 1. Examples of people's dra

while others used very light pen strokes. Lastly, some patientsdrew expressions of emotions on their face while others drewno emotional expressions. We classified drawings intocategories based on the number of pain areas drawn, whetheran external force was drawn, and whether facial expressionswere drawn. To measure the intensity of pen stroke, drawingswere scanned into photoshop and analysed using Image Jsoftware mean greyscale. Analyses were performed to seewhether differences in the drawings based on these variableswere associated with illness perceptions and health outcomes,as described below.

Number of pain areas

In 9% of drawings, no particular pain area could beidentified, 34% of drawings contained one area of pain, 29%

wings of their headaches.

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had two areas of pain, and the remaining 28% had three ormore pain areas. There were no differences between thesegroups on any illness perceptions or other outcomes.

External force

Twenty-seven people (41.5%) drew external force to theirhead (such as a hammer). Mann–Whitney tests showed thatthose who drew external force in their drawings rated theiraverage pain as worse (mean=6.08, S.D.=1.29) than thosewho did not draw external force (mean=5.16, S.D.=1.59; Z=−2.05, P=.04).

Thirty-two participants attributed their headaches tostress, and 33 attributed their headaches to other factorssuch as lack of sleep, dehydration, or sinus problems. Agreater proportion of people who drew external force on theirdrawings attributed their headaches to stress (19/27) thanother people did (13/38; χ2=8.29, P=.004).

Facial expressions

Facial expressions were evident in 43 of the 65 drawings(66%). There were no differences in illness perceptions orother outcomes between those who drew facial expressionsand those who did not.

Intensity of pen stroke

Darker drawings were associated with lower vitality(Spearman's ρ=−.46, P=.002) and higher emotional repre-sentations (Spearman's ρ=−.41, P=.007).

Size of the drawings

The average height of the drawings was 95.72 mm(S.D.=38.86), and the average width was 99.37 mm(S.D.=45.59). The associations between size of drawing,illness perceptions, and outcomes are shown in Table 1.

Table 1Associations between the size of patients' drawings, illness perceptions, and healt

Vertical size of

Consequences .29 ⁎

Timeline .03Control .17Treatment control .11Identity .27 ⁎

Concern .19Understanding .11Emotional representation .29 ⁎

Vitality −.28 ⁎Mental health −.17Visits to the doctor .17Worst pain .23Average pain .15Days restricted .16

⁎ Pb .05.

Larger size was associated with perceptions of worseconsequences, worse symptoms, worse emotional represen-tations, lower vitality, higher pain, and more days ofrestricted activity.

Because the SF36 mental health scale includes acombination of anxiety, depression, calmness, and happinessitems, we further investigated the association betweendrawing size and mental health using these individualitems. The item “how often in the past 4 weeks have youbeen a happy person?” was strongly associated with size(vertical size, Spearman's ρ=−.44, P=.000; horizontal size,Spearman's ρ=−.43, P=.001). The item “how often in thepast 4 weeks have you felt so down in the dumps that nothingcould cheer you up?” was also associated with both vertical(Spearman's ρ=.32, P=.01) and horizontal size (Spearman'sρ=.25, P=.04). The other items were not significantlyassociated with drawing size.

Illness perceptions

We were also interested in how people's illness percep-tions assessed using the Brief IPQ were associated withhealth outcomes; these correlations are shown in Table 2.Higher pain ratings were associated with higher conse-quences, longer timeline, lower personal control, higheridentity, and higher concern. More days restricted wereassociated with higher consequences and higher concern.More doctor visits were associated with higher consequencesand higher control perceptions. Lower vitality was asso-ciated with higher consequences and higher emotionalrepresentations. Poorer mental health was associated withhigher emotional representations.

Discussion

People's drawings of their headaches illustrated how theyexperienced their pain in a graphic way. The drawings

h outcomes

drawing Horizontal size of drawing

.31 ⁎

.02

.02−.03.09.14.05.28 ⁎

−.25 ⁎−.10.15.28 ⁎

.17

.25 ⁎

Table 2The association between illness perceptions and health outcomes

Average pain Worst pain Days restricted Number of doctor visits Vitality Mental health

Consequences .34 ⁎⁎ .37 ⁎⁎ .39 ⁎⁎ .27 ⁎ −.25 ⁎ −.14Timeline .25 ⁎ .30 ⁎ .16 −.15 −.18 .01Control −.30 ⁎ −.15 −.03 .26 ⁎ .08 .08Treatment control −.05 .06 −.13 .17 .18 .03Identity .32 ⁎ .36 ⁎ .21 .00 −.19 −.14Concern .45 ⁎⁎ .27 ⁎ .31 ⁎ −.03 −.20 −.22Understanding −.10 −.12 −.06 .03 .21 .05Emotional representation .14 .12 .16 .13 −.34 ⁎⁎ −.28 ⁎

⁎ Pb.05.⁎⁎ Pb.01.

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depicted the quality of the pain (as a stabbing dagger orheavy pressure) and the location of the pain, as well asemotional reactions to the pain through facial expressionsand behavioral reactions, such as the desire to sleep or rubthe head. The depiction of an external force to the head wascommon, and people who drew this reported high ratings ofpain and were more likely to attribute their headache to stressthan others. It could be that these people see stress as anexternal force, acting upon them physically and mentally tocause pain.

Larger drawings were associated with worse outcomes,including perceptions of greater consequences, higheremotional representations, worse symptoms, worse pain,and more days restricted. This is the first study to look at therelationship between drawing size and positive emotions andto find out that smaller drawings were associated with greaterhappiness and vitality. Drawing size may reflect theimportance of the headaches to the individual.

The use of ink in the drawings was also indicative of howthey experienced their headache. People who drew darkerdrawings reported being more emotionally affected by theirheadaches and reported lower vitality. Ink use may reflect amore unconscious expression of the person's feelingstowards the headaches. Future research needs to furtherinvestigate whether ink use varies within subjects fordrawings of different objects.

It is useful to compare these findings with earlier studies.The type of lines drawn is a variable that has been usedbefore in psychodynamic analyses [14], but we have notpreviously used this variable in our previous work with heartpatients. Heavy use of ink was particularly noticeable inheadache drawings compared to heart attack patients'drawings. External force to the affected organ was muchmore common in headache patients' drawings than in heartattack patients' drawings. This is despite the commondescription of a heart attack as crushing chest pain and thecommon stress attribution. However, the pain would havesubsided by the time the patients were asked to draw theirhearts. Heart attack patients were more likely to draw muscletissue damage, which is something that common headachesare not usually associated with. The finding that largerdrawings were associated with poorer outcomes is congruentwith the heart attack research.

The study also backs up previous findings thatheadache sufferers' illness perceptions are associatedwith health outcomes [5]. Of particular relevance forhealth care professionals is that higher control perceptionsand higher consequence perceptions were associated withmore doctor visits.

This study further demonstrates that asking patients todraw their illness is a useful technique to assess how peoplethink about their illness. The study extends the previous useof drawings to assess illness perceptions from diseases of theheart to the head. Drawing size has again been shown to bean important variable. Other features of the drawings appearto differ between illnesses, such as the depiction of tissuedamage on the heart or external force to the head; hence,these features must be analysed based on the particularillness studied. Further research could investigate the use ofdrawings to assess the perceptions of patients with othertypes of pain, such as back pain, and investigate how theseperceptions predict recovery.

This study has several limitations. The inclusion criteriaof persistent headache could have been better defined. Itwould have been useful to include a screening tool formigraine, a standard headache severity measure, andassessment of comorbid health complaints. It would alsohave been useful to collect demographic information. Somemigraine patients experience macrosomatognosia or micro-somatognosia, in which parts of the body can be perceivedas overly large or small. It would be interesting toinvestigate these perceptions in future work.

These findings suggest that this method of elicitingdrawings may be a useful tool for health practitioners toassess patients' perceptions of their headache. Drawings maybe especially useful when there are language barriersbetween the patient and health professional. Drawingsoffer a very open way for the patients to express theirviews and may reflect feelings and perceptions outside therange of some questionnaires. Components of the drawingsmay give the practitioner an insight into the patients'experience of their pain and provide potential avenues toexplore. The drawing of heavy pressure to the head, forexample, may be a good starting point for discussion aboutthe types of stress the patients feel they are under and howthey might reduce this.

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References

[1] Broadbent E, Petrie KJ, Ellis CJ, Ying J, Gamble G. A picture ofhealth—myocardial infarction patients' drawings of their hearts andsubsequent disability: a longitudinal study. J Psychosom Res 2004;57:583–7.

[2] Broadbent E, Ellis CJ, Gamble G, Petrie KJ. Changes in patientdrawings of the heart identify slow recovery following myocardialinfarction. Psychosom Med 2006;68:190–3.

[3] Reynolds L, Broadbent E, Ellis CJ, Gamble G, Petrie KJ. Patientdrawings illustrate psychological and functional status in heart failure.J Psychosom Res 2007;63:525–32.

[4] Ellertsen B. Headache and migraine. In: Ayers S, Baum A, McManus C,Newman S, Wallston K, Weinman J, West R, editors. Cambridgehandbook of psychology, health and medicine. 2nd ed. Cambridge:Cambridge University Press, 2007. pp. 724–6.

[5] Page LA, Joward LM, Husain K, Tong J, Dowson AJ, Weinman J,Wessely SC. Psychiatric morbidity and cognitive representations ofillness in chronic daily headache. J Psychosom Res 2004;57:549–55.

[6] Unruh A, McGrath P, Cunningham SJ, Humphreys P. Children'sdrawings of their pain. Pain 1983;17:385–92.

[7] Stafstrom CE, Rostasy K, Minster A. The usefulness of children'sdrawings in the diagnosis of headache. Pediatrics 2002;109:460–72.

[8] Stafstrom CE, Goldenholz SR, Dulli DA. Serial headache drawings bychildren with migraine: correlation with clinical headache status.J Child Neurol 2005;20:809–13.

[9] Wojaczyńska-Stanek K, Koprowski R, Wróbel Z, GolaM. Headache inchildren's drawings. J Child Neurol 2008;23:184–91.

[10] Masferrer R, Prendergast V, Hagell P. Colored pain drawings: preliminaryobservations in a neurosurgical practice. Eur J Pain 2003;7:213–7.

[11] Broadbent E, Petrie KJ, Main J, Weinman J. The Brief IllnessPerception Questionnaire. J Psychosom Res 2006;60:631–7.

[12] Stewart AL,Ware JE.Measuring functioning and well-being: the medicaloutcomes study approach. London: The Rand Corporation, 1993.

[13] Faul F, Erdfelder E, Lang AG, Buchner A. G⁎Power 3: a flexiblestatistical power analysis program for the social, behavioral, andbiomedical sciences. Behav Res Methods 2007;39:175–91.

[14] Machover K. Personality projection in the drawing of the humanfigure. Oxford (England): C. C. Thomas, 1949.