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Depression, Automatic Thoughts, Alexithymia,

and Assertiveness in Patients With Tension‐
type Headache

Article in Headache The Journal of Head and Face Pain · February 2002
Impact Factor: 2.71 · DOI: 10.1046/j.1526-4610.2002.02051.x

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 Depression, Automatic Thoughts, Alexithymia, and
Assertiveness in Patients With Tension-type Headache
Basak Yücel, MD; Kaan Kora, MD; Süleyman Özyalçín, MD; Nilüfer Alçalar, PhD;
Özay Özdemir, MD; Aysen Yücel, MD

Objective.—The role of psychological factors related to headache has long been a focus of investigation. The
aim of this study was to evaluate depression, automatic thoughts, alexithymia, and assertiveness in persons with
tension-type headache and to compare the results with those from healthy controls.
Methods.—One hundred five subjects with tension-type headache (according to the criteria of the Interna-
tional Headache Society classification) and 70 controls were studied. The Beck Depression Inventory, Automatic
Thoughts Scale, Toronto Alexithymia Scale, and Rathus Assertiveness Schedule were administered to both
groups. Sociodemographic variables and headache features were evaluated via a semistructured scale.
Results.—Compared with healthy controls, the subjects with headache had significantly higher scores on
measures of depression, automatic thoughts, and alexithymia and lower scores on assertiveness. Subjects with
chronic tension-type headache had higher depression and automatic thoughts scores than those with episodic ten-
sion-type headache.
Conclusions.—These findings suggested that persons with tension-type headache have high depression scores
and also may have difficulty with expression of their emotions. Headache frequency appears to influence the like-
lihood of coexisting depression.
Key words: tension-type headache, depression, automatic thoughts, alexithymia, assertiveness
Abbreviations: TTH tension-type headache, ETTH episodic tension-type headache, CTTH chronic tension-type
headache, BDI Beck Depression Inventory, ATS Automatic Thoughts Scale, TAS Toronto Al-
exithymia Scale, RAS Rathus Assertiveness Schedule
(Headache. 2002;42:194-199)

The role of psychological factors in chronic head-
ache has been investigated extensively.1-5 The psychi-
atric disorder most frequently observed to accom-
pany chronic headache is depression.6,7 According to
the cognitive model of depression, functionally disor-
dered cognition plays an important role in the emer-
From the Departments of Psychiatry, University of Istanbul
(Drs. B. Yücel and Alçalar) and the University of Marmara,
Istanbul (Dr. Kora); the Department of Anesthesiology, Divi-
sion of Algology, University of Istanbul (Drs. Özyalçín and A.
Yücel); and Acibadem Hospital, Istanbul (Dr. Özdemir),
Turkey.
Address all correspondence to Dr. Basak Yücel, Department
of Psychiatry, University of Istanbul, Capa-34390, Istanbul,
Turkey.
Accepted for publication December 10, 2001.
gence and perpetuation of depression. Activation of
functionally disordered cognition in individuals prone
to depression facilitates “automatic” emergence of
negative thoughts. These negative automatic thoughts
reinforce and nourish underlying beliefs and pre-
sumptions that themselves are depressive in origin,
and as the negative automatic thoughts intensify, de-
pression becomes more severe.8 Levels of depression
are parallel to the cognitive distortions experienced
by patients with chronic pain.9
Coined by Sifneos, the term alexithymia (literally
“no words for feelings”) denotes a striking disturbance
of psychic functioning characterized by difficulties in
the verbalization of affect and elaboration of fanta-
sies.10,11 Alexithymic characteristics have been described
in psychosomatic illness and various types of somatiza-
tion.11-14 It is claimed that patients with chronic pain
syndrome are quite frequently alexithymic.15-17

194
Headache
Assertiveness can be defined as the ability to ex-
press one’s own thoughts, feelings, and beliefs in an
explicit and appropriate manner, and to show respect
for other’s rights while protecting one’s own.18,19 The
assertive personality finds it relatively easy to make a
request, to reject the requests of others, and to en-
dure the consequences of being rejected.
Psychological and psychiatric factors appear to
play an important role in tension-type headache
(TTH).20 In our clinical population, patients with
TTH appear to have a particular difficulty in recog-
nizing and expressing their feelings and in expressing
their wishes (out of the concern that they might hurt
others). Some investigators have postulated that head-
ache is associated with unexpressed aggression and
hostility, and patients with headache, indeed, may
have difficulties in recognizing and expressing their
feelings.21,22 We can speculate that patients with
chronic headache may be alexithymic and nonasser-
tive and that their depression levels are high. In this
study, we evaluated and compared the subjects with
TTH with a healthy control group, evaluating each
for depression, automatic thoughts, alexithymia, and
assertiveness.
SUBJECTS AND METHODS
Subjects.—One hundred five subjects with TTH
were randomly selected from a population of 600 pa-
tients evaluated for headache for the first time be-
tween 1998 and 2000 at our university-based pain
clinic. We defined the following inclusion criteria: 18
to 65 years of age, at least primary school education,
meets International Headache Society (IHS) diag-
nostic criteria for episodic tension-type headache
(ETTH) or chronic tension-type headache (CTTH),23
and has had TTH for at least 1 year.
Exclusion criteria were: other, coexisting, primary
headache disorders or combined headache according
to the IHS criteria; serious systemic disease (ie, he-
patic, cardiac, or renal) or neurologic disorder; or an
inability or unwillingness to cooperate.
Seventy headache-free subjects were chosen ran-
domly from the general population and matched with
the TTH group for age, gender, level of education,
and occupation.
195
Instruments.—Semistructured questionnaires, the
Beck Depression Inventory (BDI), Automatic Thoughts
Scale (ATS), Toronto Alexithymia Scale (TAS), and
Rathus Assertiveness Schedule (RAS), were adminis-
tered to the subjects with TTH and to the control group.
All the psychological tests were verified for their valid-
ity and reliability in Turkish.18,24-27
The BDI is an instrument for measuring the so-
matic, emotional, cognitive, and motivational symp-
toms observed in depression. It comprises 21 symptom-
related categories and is used to identify the severity of
depression.28 The ATS measures the frequency of the
emergence of automatic negative thoughts attributed
to depression. In this scale comprised of 30 items, the
subject is asked to mark one of the options of “never,”
“sometimes,” “quite often,” “often,” or “always” for
each item. The answers are then scored on a 1-to-5-
point scale.29 The TAS is comprised of 26 questions
used for self-report. Those who obtain 11 or more
points at the end of the scale are considered alexithy-
mic.26,27 The RAS is a 30-item test which measures as-
sertiveness. Each item can be measured as “very poor”
(3), “poor” (2), “fair” (1), “a little appropriate”
(1), “good appropriate” (2), or “very good appro-
priate” (3). By adding positive and negative scores
separately and subtracting the sums from each other,
the total score of the inventory can be calculated. The
total score can be found between 90 and 90. Those
who are found to be 10 and below are considered to
be unassertive, whereas those who are above 10 are
considered to be assertive.30
Statistics.—The Mann-Whitney U test was used
for comparisons between the groups of continuous
variables like test scores. The chi-square test was
used for comparisons of categorical variables. For
analysis of correlations between variables, the Spear-
man correlation test was performed. For the analyses,
the Statistical Package for the Social Sciences (SPSS),
Version 6.0 computer program was used. The level of
statistical significance was set at P.05.
RESULTS
Sociodemographic Findings and Headache Char-
acteristics.—The sociodemographic characteristics of
the groups are listed in Table 1. The age range in the
196 March 2002

Table 1.—Sociodemographic Characteristics of Tension- Table 2.—Gender Differences in Distribution of Scale

type Headache and Control Groups* Scores for the Tension-type Headache Group*

Headache Control Scale Female (n82) Male (n23) P

Group Group
Feature (n105) (n70) P
Beck Depression
Inventory 16.5 (17.9910.17) 12 (13.788.52) NS
Age, meanSD, y 3310 349 NS Automatic
Gender NS Thoughts Scale 57.5 (61.525.85) 52 (53.1317.24) NS
Male 23 (22) 16 (23) Toronto
Female 82 (78) 54 (77) Alexithymia
Marital status NS Scale 11 (10.874.23) 11 (11.254.15) NS
Married 75 (71) 52 (74) Rathus
Other 30 (29) 18 (26) Assertiveness
Education NS Schedule 15 (11.6623.27) 8 (0.1432.87) NS
Primary 24 (23) 24 (34)
Secondary 11 (11) 5 (7)
High 32 (31) 13 (19) *Values are median (meanSD).
University 38 (36) 28 (40)
Occupation NS
Worker 62 (59) 38 (54)
Nonworker 43 (41) 32 (46)

The median ATS score for subjects with TTH was

*Values are number (percentage) unless otherwise indicated. 55 (range, 8 to 123) compared with 43 (range, 30 to 66)
in the control group. This difference, too, was statisti-
cally significant (U2285, z4.2, P.001) (Table 3).
headache group was 18 to 59 years, and 21 to 65 years The analysis of the correlation between the BDI
in the control group. No significant difference in age, and the ATS scores demonstrated that there was a
gender, distribution, marital status, education, and positive correlation for both groups (headache group:
occupation existed between the groups. r0.8, P.001; control group: r0.3, P.007).
About half of those with headache (n53,
50.5%) had ETTH, and 49.5% (n52) had CTTH.
The mean duration of headache history was 129 Table 3.—Distribution of Scale Scores in the Tension-type
Headache and Control Groups*
years (range, 1 to 44 years) in the ETTH subgroup
and 99 years (range, 1 to 34 years) in the CTTH
subgroup (P.05). In the TTH group as a whole, Headache Control
Group Group
there were no significant variations in scale scores ac-
Scale (n105) (n70) P
cording to gender (Table 2).
Comparisons Between TTH and Control Groups.—
Beck
The scores obtained from the scales that were admin-
Depression
istered are listed in Table 3. Inventory 16 (17.059.94) 8.5 (9.876.06) .001
The median BDI score of the headache group Automatic
Thoughts
was 16 (range, 1 to 40), whereas that of the control
Scale 55 (59.6724.4) 43 (44.469.93) .001
group was 8.5 (range, 0 to 28); this difference was sta- Toronto
tistically significant (U2063.5, z4.7, P.001). The Alexithymia
Scale 11 (11.04.2) 8 (8.223.69) .001
severity of depressive symptoms was assessed for both Rathus
groups on the basis of the scores obtained from the Assertiveness
BDI (Table 4), and a substantially significant differ- Schedule 14 (9.1225.92) 22 (20.8323.29) .007
ence was found, indicating greater severity of depres-
sion in the TTH group (222.58, df2, P.001). *Values are median (meanSD).
Headache 197

Table 4.—Comparison of Severity Levels of Depression in Scores for ATS and BDI were higher, and RAS
Tension-type Headache and Control Groups* scores lower in the CTTH subgroup than in the
ETTH subgroup. For BDI and ATS scores, the dif-
Headache Control ferences were statistically significant (Table 5).
Group Group When the ETTH and CTTH subgroups were
Level of Depression (n105) (n70)
compared separately with the control group, BDI,
ATS, and TAS scores were higher in the ETTH sub-
No depression (0-13) 44 (43) 54 (77)
group than in the control group (U1280.5, z2.7,
Depression of medium severity (14-24) 37 (36) 14 (20)
Severe depression (25) 22 (21) 2 (3) P.005; U1405.5, z2.3, P.02; U1190.0, z3.3,
P.001, respectively). For the CTTH subgroup, BDI
*Based on Beck Depression Inventory Scores. Values are
scores (U783.0, z5.2, P.001), ATS scores (U880.0,
number (percentage). 222.58, df2, P.001. z4.8, P.001), and TAS scores (U1056.0, z3.8,
P.001) were higher, and RAS scores (U1219.5,
z3.1, P.002) lower than in the control group.
The median TAS score for subjects with head-
ache was 11 (range, 2 to 19), whereas that of the con-
COMMENTS
trol group was 8 (range, 2 to 17); these median TAS
Various investigators have reported the associa-
scores were significantly different (U2246, z4.2,
tion of chronic headache with depression.31-36 Hol-
P.001) (Table 3). When the alexithymia scores of
royd et al reported that BDI scores were elevated in
the individuals in both groups were analyzed, signifi-
patients with CTTH relative to healthy controls.35
cantly more (56%) of the headache group than the
Similarly, we found a mean BDI score in our CTTH
control group (29%) were found to be alexithymic
subgroup that was significantly higher than the score
(Fisher exact test, P.001).
recorded from the healthy control group. We also
The median score of the TTH group on the RAS
found higher BDI scores in the ETTH subgroup than
was 14 (range, 95 to 64), whereas the median of the
in the control group, and 57% of our subjects with
control group was 22 (range, 26 to 74) (U2709,
TTH had depressive symptoms of medium or high se-
z2.6, P.007) (Table 3).
verity. These findings suggest that clinically signifi-
cant depression is common in persons with TTH.
Some investigators propose that cognitive re-
structuring is important to the development of both
Table 5.—Comparison of Scale Scores Between Episodic
and Chronic Tension-type Headache Subgroups* chronic pain and depression. In studies conducted
with patients suffering from chronic low back pain,
Lefebvre found that the severity of a patient’s de-
Episodic Chronic
Group Group pression paralleled his/her cognitive distortions.9 We
Scale (n53) (n52) P could not find any published study which has exam-
ined the automatic thoughts of patients with head-
Beck Depression ache. In the present study, we found that ATS scores
Inventory 15 (14.949.5) 16 (19.1210.0) .028 of subjects with TTH appear to be significantly
Automatic
higher than those of healthy individuals. High scores
Thoughts Scale 50 (55.4724.67) 62 (63.9723.59) .034
Toronto for depression and automatic thoughts support Beck’s
Alexithymia contention that cognitive restructuring represents a
Scale 11 (10.734.22) 11 (11.284.19) NS
Rathus
risk factor for the development of depression.8
Assertiveness Alexithymia has been identified as a factor which
Schedule 19 (12.0425.74) 10 (6.326.02) NS facilitates the emergence of psychosomatic disorders
and is encountered at higher frequency in cases of
*Values are median (meanSD). psychosomatic diseases and somatoform disorders.10
198
Patients with headache may experience difficulties in
expressing their emotions, and as their headache syn-
drome becomes more severe, the tendency of the af-
flicted to reject the stress effects become more obvi-
ous.37 Wise et al found the levels of alexithymia in
patients with headache to approximate those re-
corded in psychiatric outpatients.14 Our findings indi-
cate that in those with TTH, alexithymia is signifi-
cantly more common and pronounced than in a
healthy control group.
Difficulties in interpersonal communication arise
from the individual’s difficulty in articulating his/her
emotions and wishes. Assertiveness, one of the pat-
terns of behavior that provides the means for ade-
quate interpersonal communication, involves direct and
sincere expression of emotions, beliefs, and thoughts,
along with the communication of respect towards
others.18 Using the RAS, we found that the assertive-
ness scores of our subjects with TTH were signifi-
cantly lower than those of the control group. This re-
sult seems to be in accord with our clinical observations
indicating that subjects with TTH in our practice ex-
perience difficulty in expressing their emotions (espe-
cially negative) and wishes.
Although our results point to the importance of
psychological factors in TTH and may contribute to
the understanding and treatment of this primary
headache disorder, there is need for further studies to
confirm and expand upon our findings.
Acknowledgment: Appreciation is expressed to Ha-
kan Çamlíca, MD from the Department of Cancer Epide-
miology and Biostatistics in Istanbul Medical Faculty for
his contributions in statistical analyses.
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