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   <front>
      <journal-meta>
         <journal-id journal-id-type="publisher-id">EJOP</journal-id>
         <journal-id journal-id-type="nlm-ta">Eur J Psychol</journal-id>
         <journal-title-group>
            <journal-title>Europe's Journal of Psychology</journal-title>
            <abbrev-journal-title abbrev-type="pubmed">Eur. J. Psychol.</abbrev-journal-title>
         </journal-title-group>
         <issn pub-type="epub">1841-0413</issn>
         <publisher>
            <publisher-name>PsychOpen</publisher-name>
         </publisher>
      </journal-meta>

ejop.v8i3.308

10.5964/ejop.v8i3.308

            <subj-group subj-group-type="heading">
               <subject>Research Reports</subject>
            </subj-group>

         <title-group>

Emotional Status, Perceived Control of Pain, and Pain Coping Strategies
               in Episodic and Chronic Cluster Headache

            <trans-title-group xml:lang="de">
               <trans-title>Emotional Communication on Romantic Relationships: Design and Validation
                  of a Measure in Mexico</trans-title>
            </trans-title-group>
            <alt-title alt-title-type="right-running">Cluster Headache</alt-title>
         </title-group>
         <contrib-group>
            <contrib contrib-type="editor">
               <name>
                  <surname>Allen</surname>
                  <given-names>Andrew</given-names>
               </name>
               <xref ref-type="aff" rid="aff2"/>
            </contrib>
            <contrib contrib-type="author" corresp="yes" id="contnr1" xlink:href="ejop.v10i2.810-f1">
               <name name-style="western">
                  <surname>Zahavi</surname>
                  <given-names>Dan</given-names>
               </name>

               <bio>

<bold>Dan Zahavi</bold> is Professor of Philosophy and Director of the Center
                     for Subjectivity Research at the University of Copenhagen. He obtained his
                     Ph.D. from Katholieke Universiteit Leuven in 1994 and his Dr.phil.
                     (Habilitation) from University of Copenhagen in 1999. He has served as
                     president of the Nordic Society for Phenomenology in the years 2001-2007, and
                     is currently co-editor in chief of the journal Phenomenology and the Cognitive
                     Sciences. In his systematic work, Zahavi has mainly been investigating the
                     nature of selfhood, self-consciousness and intersubjectivity. His most
                     important publications include <italic>Husserl und die transzendentale
                        Intersubjektivität</italic> (Kluwer 1996), <italic>Self-awareness and
                        Alterity</italic> (Northwestern University Press 1999), <italic>Husserl's
                        Phenomenology</italic> (Stanford University Press 2003),
                        <italic>Subjectivity and Selfhood</italic> (MIT Press 2005), and together
                     with Shaun Gallagher <italic>The Phenomenological Mind</italic> (Routledge
                     2008).

               </bio>
               <xref ref-type="corresp" rid="cor1">
                  *
               </xref>
               <xref ref-type="aff" rid="aff1">
                  a
               </xref>
            </contrib>
            <contrib contrib-type="author">
               <name>
                  <surname>Valade</surname>
                  <given-names>Dominique</given-names>
               </name>
               <xref ref-type="aff" rid="aff1">
                  a
               </xref>
            </contrib>
            <contrib contrib-type="author">
               <name>
                  <surname>Fontenelle</surname>
                  <given-names>Frédéric</given-names>
               </name>
               <xref ref-type="aff" rid="aff2">
                  b
               </xref>
            </contrib>
            <contrib contrib-type="author">
               <name>
                  <surname>Roos</surname>
                  <given-names>Caroline</given-names>
               </name>
               <xref ref-type="aff" rid="aff1">
                  a
               </xref>
            </contrib>
            <contrib contrib-type="author">
               <name>
                  <surname>Rousseau-Salvador</surname>
                  <given-names>Céline</given-names>
               </name>
               <xref ref-type="aff" rid="aff2">
                  b
               </xref>
               <xref ref-type="aff" rid="aff3">
                  c
               </xref>
            </contrib>
            <contrib contrib-type="author">
               <name>
                  <surname>Ducros</surname>
                  <given-names>Anne</given-names>
               </name>
               <xref ref-type="aff" rid="aff1">
                  a
               </xref>
            </contrib>

            <contrib contrib-type="author" corresp="yes">
               <name>
                  <surname>Rusinek</surname>
                  <given-names>Stéphane</given-names>
               </name>
               <xref ref-type="corresp" rid="cor1">
                  *
               </xref>
               <xref ref-type="aff" rid="aff2">
                  b
               </xref>
            </contrib>

            <aff id="aff1">aEmergency Headache Centre, Lariboisiere Hospital, Paris,
               France</aff>
            <aff id="aff2">bDepartment of Psychology, University of Lille
               Nord-de-France, UDL3, Villeneuve d'Ascq, France</aff>
            <aff id="aff3">cService of Pediatric Hematology and Oncology, Trousseau
               Hospital, Paris, France<country>France</country></aff>
         </contrib-group>
         <author-notes>
            <corresp id="cor1">*Laboratoire PSITEC, Université de Lille
               Nord-de-France, UDL3, B.P. 06149, 59 653 Villeneuve d'Ascq Cedex, France, email:
                  <email xlink:href="stephane.rusinek@univ-lille3.fr">stephane.rusinek@univ-lille3.fr</email>,
                  <email xlink:href="smit.indoo@gmail.com">smit.indoo@gmail.com</email>,
                  <email xlink:href="singhindu64@rediffmail.com">singhindu64@rediffmail.com</email> tel.: + 33 3 20 41 67 87</corresp>
         </author-notes>
         <pub-date pub-type="ppub">
            <day>29</day>
            <month>08</month>
            <year>2012</year>
         </pub-date>
         <volume>8</volume>
         <issue>3</issue>
         <fpage>461</fpage>
         <lpage>474</lpage>
         <history>
            <date date-type="received">
               <day>14</day>
               <month>03</month>
               <year>2012</year>
            </date>
            <date date-type="accepted">
               <day>27</day>
               <month>05</month>
               <year>2012</year>
            </date>
            <date date-type="corrected">
               <day>30</day>
               <month>08</month>
               <year>2013</year>
            </date>
         </history>
         <product product-type="book" id="p1">
            <person-group person-group-type="author">
               <name name-style="western">
                  <surname>Hatfield</surname>
                  <given-names>Gary</given-names>
               </name>
               <name name-style="western">
                  <surname>Allred</surname>
                  <given-names>Sarah</given-names>
               </name>
            </person-group>
            <role>Eds.</role>
            <source>Visual Experience: Sensation, Cognition and Constancy</source>
            <publisher-loc>Oxford, United Kingdom</publisher-loc>
            <publisher-name>Oxford University Press</publisher-name>
            <year>2012</year>
            <size units="page">264</size>
            <isbn>9780199597277</isbn>
            <inline-graphic xlink:href="ejop.v10i1.731-f1"/>
         </product>

         <permissions>
            <copyright-year/>
            <copyright-holder/>
            <license license-type="open-access"
               xlink:href="http://creativecommons.org/licenses/by/3.0/">
               <license-p>This is an open-access article distributed under the terms of the Creative
                  Commons Attribution License, which permits unrestricted use, distribution, and
                  reproduction in any medium, provided the original work is properly
                  cited.</license-p>
            </license>
         </permissions>
         <abstract xml:lang="fr">

Cluster headache (CH) is a chronic syndrome characterized by excruciatingly painful
               attacks occurring with circadian and circannual periodicity. The objectives of the
               present study were, in CH patients, to determine by principal component analysis the
               factor structure of two instruments commonly used in clinics to evaluate pain locus
               of control (Cancer Locus of Control Scale–CLCS) and coping strategies (Coping
               Strategies Questionnaire–CSQ), to examine the relationship between internal pain
               controllability and emotional distress, and to compare psychosocial distress and
               coping strategies between two subsets of patients with episodic or chronic CH.
               Results indicate, for CLCS, a 3-factor structure (internal controllability, medical
               controllability, religious controllability) noticeably different in CH patients from
               the structure reported in patients with other painful pathologies and, for CSQ, a
               5-factor structure of CSQ which did not markedly diverge from the classical
               structure. Perceived internal controllability of pain was strongly correlated with
               study measures of depression (HAD depression/anhedonia subscale, Beck Depression
               Inventory). Comparison between subsets of patients with episodic or chronic CH of
               emotional status, pain locus of control, perceived social support and coping
               strategies did not reveal significant differences apart for the Reinterpreting pain
               sensations strategy which was more often used by episodic CH patients. Observed
               tendencies for increased anxiety and perceived social support in patients with
               episodic CH, and for increased depression and more frequent use of the Ignoring pain
               sensations strategy in patients with chronic CH, warrant confirmation in larger
               groups of patients.

         </abstract>
         <kwd-group kwd-group-type="author" xml:lang="EN">
            <kwd>cluster headache</kwd>
            <kwd>anxiety</kwd>
            <kwd>depression</kwd>
            <kwd>pain locus of control</kwd>
            <kwd>coping strategies</kwd>
         </kwd-group>

   </front>

Cluster headache (CH) is a member of the trigeminal autonomic cephalalgias which form a
         group of primary disorders characterized by unilateral trigeminal distribution pain
         occurring in association with prominent ipsilateral cranial autonomic features. It is an
         excruciating syndrome, and probably constitutes the most painful condition known to humans
            (<xref ref-type="bibr" rid="r26">Matharu & Goadsby, 2002</xref>). The prevalence of
         CH is estimated to be about 0.01-0.03% (<xref ref-type="bibr" rid="r19">Katsarava et al.,
            2007</xref>; <xref ref-type="bibr" rid="r25">Manzoni & Stovner, 2010</xref>), and
         more men than women are affected (<xref ref-type="bibr" rid="r24">Manzoni, 1998</xref>;
            <xref ref-type="bibr" rid="r13">Donnet et al., 2007</xref>; <xref ref-type="bibr"
            rid="r14">Fischera, Marziniak, Gralow, & Evers, 2008</xref>).

CH is characterized by a striking circannual and circadian periodicity. Its etiology is
         unknown but physiopathology may involve the trigeminal nociceptive pathways, the autonomic
         system and the posterior hypothalamic gray matter (<xref ref-type="bibr" rid="r22"
            >Lanteri-Minet, 2003</xref>). Attacks occur in series (cluster periods)–from once every
         other day up to eight times a day–lasting for weeks or months, separated by remission
         periods usually lasting months or years. In episodic CH, cluster periods of one week to one
         year are separated by pain-free periods of one month or longer, while in chronic CH the
         attacks may occur for more than one year without remission or remissions lasting less than
         one month (<xref ref-type="bibr" rid="r16">Headache Classification Subcommittee of the
            International Headache Society, 2004</xref>).

Chronic pain has physical, psychological and social impacts on patients, affecting
         confidence to cope with pain, accomplish life goals, live a normal lifestyle, and maintain
         normal social and leisure activities. In order to cope with and adjust to the burden of
         pain, chronic pain patients develop a range of cognitive, emotional and behavioral
         strategies, according to pre-existing personality characteristics, some of which (e.g.,
         passive coping and dramatizing/catastrophizing) eventually play a pejorative role in
         pain-related disability and depression (<xref ref-type="bibr" rid="r9">Brown &
            Nicassio, 1987</xref>; <xref ref-type="bibr" rid="r34">Snow-Turek, Norris, & Tan
            1996</xref>; <xref ref-type="bibr" rid="r2">Arnstein, Caudill, Mandle, Norris, &
            Beasley, 1999</xref>; <xref ref-type="bibr" rid="r3">Asghari & Nicholas,
         2001</xref>; <xref ref-type="bibr" rid="r4">Asghari & Nicholas, 2006</xref>; <xref
            ref-type="bibr" rid="r21">Koleck, Mazaux, Rascle, & Bruchon-Schweitzer, 2006</xref>;
            <xref ref-type="bibr" rid="r27">Mongini et al., 2009</xref>).

As CH has some specificities among chronic painful pathologies, one of the objectives of
         the present study was to determine in CH patients, by principal component analysis, the
         factor structure of two instruments widely used in research and clinics to evaluate
         perceived control of the disease and pain coping strategies (Cancer Locus of Control
         Scale–CLCS–and Coping Strategies Questionnaire–CSQ–, respectively) (<xref ref-type="bibr"
            rid="r33">Rosenstiel & Keefe, 1983</xref>; <xref ref-type="bibr" rid="r28">Pruyn et
            al., 1988</xref>) and to compare results with the factor structures reported for the
         same instruments in other categories of chronic pain patients. To the best of our
         knowledge, CLCS had not been used in CH patients as yet. Since pain patients' attitude
         towards pain sensations, beside pain intensity, is known to influence psychological
         outcomes (<xref ref-type="bibr" rid="r2">Arnstein et al., 1999</xref>; <xref
            ref-type="bibr" rid="r3">Asghari & Nicholas, 2001</xref>), the relationship between
         perceived pain control and emotional distress was also examined. Finally, hypothesizing
         that duration and periodicity of pain episodes may affect pain levels and functional
         outcomes in CH patients, another objective of the study was to compare psychosocial
         distress and pain coping strategies between subsets of patients with episodic or chronic
         CH.

      <sec sec-type="methods" xml:lang="jp">
         <title>Methods</title>
         <sec>
            <title>Study Setting – Participants</title>

This was a cross-sectional, observational study carried out from November 2004 to
               July 2005 among patients consulting at the Emergency headache center ('Centre
               d'Urgences Céphalées'–CUC) of Lariboisiere hospital in Paris. Patients who accepted
               to participate were administered a series of questionnaires exploring emotional
               status, perceived pain control and social support, pain-related disability and
               coping. As the survey did not cause any change in disease management, no approval
               from institutional ethics committee was required. Nevertheless, patients signed
               informed consent to participate prior to any study procedure was performed.

The patients seen at the CUC are those who need urgent medical care, i.e., patients
               who present with an abrupt recent-onset headache or with an acute recurrent attack of
               headache not relieved by the usual treatments. Approximately two thirds of these
               patients suffer from primary headaches and about 5% from CH (<xref ref-type="bibr"
                  rid="r37">Valade, 2005</xref>). All patients included in the survey had episodic
               or chronic CH diagnosed according to the International Headache Society criteria
                  (<xref ref-type="bibr" rid="r16">Headache Classification Subcommittee of the
                  International Headache Society, 2004</xref>) and had experienced a cluster period
               within the past three weeks. Possible past or concomitant organic or mental diseases
               were not taken into account for patient recruitment. Demographic attributes and
               history of the disease were recorded at patient inclusion.

         </sec>
         <sec>
            <title>Measuring Instruments</title>

Emotional status was measured with the French version (<xref ref-type="bibr"
                  rid="r23">Lépine, Godchau, Brun, & Lemperière, 1985</xref>) of the Hospital
               Anxiety and Depression (HAD) scale (<xref ref-type="bibr" rid="r41">Zigmond &
                  Snaith, 1983</xref>). This is a 14-point scale which contains seven questions on
               anxiety symptoms and seven on depressive symptoms. The depression scale was
               constructed so that it does not contain items relating to symptoms that may be caused
               by the physical illness and emphasizes anhedonia (inability to feel pleased). The HAD
               scale has been in widespread use and is currently recommended by the French national
               medico-economic evaluation service for use in chronic pain patients (Agence Nationale
               d'Accréditation et d'Evaluation en Santé (ANAES), 1999). Each item is scored from 0
               to 3 on the basis of average mood over the last ten days. Scores of 8 or over at the
               anxiety or depression scale were taken as indicative of anxiety or depression,
               respectively.

Depression was assessed with the French version (<xref ref-type="bibr" rid="r11"
                  >Collet & Cottraux, 1986</xref>) of the short-form (13-item) of the Beck
               Depression Inventory (BDI) (<xref ref-type="bibr" rid="r6">Beck, Ward, Mendelson,
                  Mock, & Erbaugh, 1961</xref>). This validated abbreviated questionnaire
               contains only the items that are most strongly correlated with total score at the
               original questionnaire and with clinical evaluation of depression severity. It
               retains the original cognition triad described by Beck: negative thoughts about
               oneself, about the external world, and about the future (<xref ref-type="bibr"
                  rid="r7">Beck, Steer, & Carbin, 1988</xref>). Each item is scored from 0 to 3
               on the basis of patient's current mood state. For the study, scores of 4-7 were
               considered indicative of mild depression, scores of 8-15 of moderate depression, and
               scores of 16 or greater of severe depression.

Perceived control was assessed with a French version of the CLCS (<xref
                  ref-type="bibr" rid="r28">Pruyn et al., 1988</xref>; <xref ref-type="bibr"
                  rid="r40">Watson, Pruyn, Greer, & Van Den Borne, 1990</xref>) which had
               previously been used in research in France (<xref ref-type="bibr" rid="r12"
                  >Cousson-Gélie, 1997</xref>; <xref ref-type="bibr" rid="r20">Koleck, 2000</xref>)
               in patients suffering from a chronic disease or chronic pain, except that "pain" was
               taken as "the disease". The French version has been validated (<xref ref-type="bibr"
                  rid="r10">Bruchon-Schweitzer, 2001</xref>). This 17-item questionnaire assesses
               three different types of cognitions: internal or external estimated locus of control
               of disease progression; internal or external causative attributions of the origin of
               the disease; ascription of the disease to God and internal/external control through
               patient's religion. Each item is scored from 0 to 3 according to intensity of patient
               agreement/disagreement with each statement. A summed score is obtained for each
               psychological dimension explored by the questionnaire.

Perceived social support was assessed with the validated French version (<xref
                  ref-type="bibr" rid="r30">Rascle et al., 1997</xref>) of the 6-item abbreviated
               Social Support Questionnaire (SSQ-6). This questionnaire measures the number of
               people to whom the patients could turn and on whom they could rely in given sets of
               circumstances (availability: scores 0-9 persons) and the corresponding satisfaction
               retrieved from the support given (satisfaction: scores 1-6). Different areas of
               support (emotional, self-esteem, information, practical) are explored. Total scores
               of availability (0-54) and satisfaction (6-36) are obtained by summing individual
               scores at the corresponding items.

Coping with pain was assessed by the French version (<xref ref-type="bibr" rid="r20"
                  >Koleck, 2000</xref>; <xref ref-type="bibr" rid="r17">Irachabal, 2002</xref>) of
               the CSQ (<xref ref-type="bibr" rid="r33">Rosenstiel & Keefe, 1983</xref>). This
               questionnaire is the most widely used measure of behavioral and emotional adjustment
               to chronic pain. The original version is comprised of 48 individual items. The French
               version is comprised of only 21 items and does not contain coping self-statements and
               behavioral coping. For each item of the questionnaire, patients are invited to score
               (from 0 to 4) the frequency of use of the proposed strategy. The sum of scores is
               calculated for each coping strategy.

Pain-related disability was assessed by the 6-item Headache Impact Test (HIT-6)
                  (<xref ref-type="bibr" rid="r5">Bayliss et al., 2003</xref>) which is an
               abbreviated and validated form of the original 54-item questionnaire (<xref
                  ref-type="bibr" rid="r8">Bjorner et al., 2003</xref>). HIT was developed by
               applying the Item Response Theory and other psychometric techniques to widely used
               questionnaires of headache impact (<xref ref-type="bibr" rid="r39">Ware, Bjorner,
                  & Kosinski, 2000</xref>). Headache severity and frequency of headache-related
               disabling symptoms (limitation in activities, tiredness, being fed up or irritated,
               difficulty in concentrating) in the past four weeks are scored from 0 to 4. For
               analysis of study data, a total score >55 (score above which an immediate medical
               appointment is recommended) was considered to indicate a significant disrupting
               effect of pain on patient's life. A French version (QualityMetric, Inc. and
               GlaxoSmithKline Group of Companies, 2000) has been used in France to measure the
               impact of migraine on patient physical, social and emotional functioning (<xref
                  ref-type="bibr" rid="r38">Vuillaume De Diego & Lanteri-Minet,
               2005</xref>).

         </sec>
         <sec>
            <title>Statistical Analysis</title>

Factor structure of the CLCS was determined in the whole sample of study CH patients
               by principal component extraction followed by normalized orthogonal varimax rotation
               to identify clusters of variables (sets of inter-correlated items). Which items were
               strongly associated with the considered factors was determined by the factor loading:
               items with a factor loading less than .40 were deleted for analysis. Internal
               consistency of each identified factor was measured by Cronbach's α coefficient.
               Factor analysis of the CSQ was determined similarly, except that it was based on an
                  <italic>a priori</italic> 5-factor (strategy) structure.

Secondarily, two subsets of patients with episodic or chronic CH were compared for a
               series of variables (anxiety and depression, perceived controllability of the
               disease, perceived social support, coping with pain) after controlling for a number
               of factors (age, age at disease onset, age at diagnostic, time before diagnostic,
               disease duration, perceived level of headache-related disability).

Relationships between perceived controllability (total score at all items grouped
               together in the corresponding CLCS factor) and depression (scores at the HAD
               depression/anhedonia subscale, the HAD global scale, and the BDI) were determined by
               correlation analyses. Inter-relationships between all depression and anxiety scores
               were also determined in pairs by computing the relevant correlation coefficients.

Continuous variables were summarized by the mean and standard deviation (SD).
               Homogeneity of variances was assessed by F tests. Data normality was assessed by the
               Kolmogorov-Smirnov test. Comparison of independent data was performed by Student's t
               tests. Linear correlations were assessed by the Bravais-Pearson correlation
               coefficient. Probability values less than or equal to 0.01 were considered to be
               statistically significant. All statistical analyses were performed with the Statview
               software version 5.

         </sec>
      </sec>
      <sec sec-type="results">
         <title>Results</title>
         <sec>
            <title>Patient Characteristics and Main Disease Features</title>

A total of 73 CH patients (64 men, 87.7%) aged between 21 and 80 years (mean age: 40
               ± 13 years) participated in the study. Of them, 56 had episodic CH (49 men, 87.5%)
               and 17 had chronic CH (15 men, 88.2%). Mean age at symptom onset was 29 ± 13 years.
               Mean disease duration was 11 ± 9 years. Mean time between symptom onset and
               diagnostic was 5 ± 7 years. Patient characteristics according to CH type (episodic,
               chronic) are presented in <xref ref-type="table" rid="t1">Table 1</xref>.

               Table 1

                  <title>Demographic Attributes and Main Disease Features of Study Patients
                     According to the Type (Episodic or Chronic) of Cluster Headache</title>

                  <col align="left" width="40%"/>
                  <col align="center" width="20%"/>
                  <col align="center" width="20%"/>
                  <col align="center" width="20%"/>

                        Patient characteristics
                        Episodic CH<break/>N = 56
                        Chronic CH<break/>N = 17
                        All patients<break/>N = 73

                        Male sex (n, %)
                        49 (87.5)
                        15 (88.2)
                        64 (87.7)

                        Age (mean ± SD)
                        38 ± 12
                        46 ± 16
                        40 ± 13

                        Age at symptom onset (mean ± SD)
                        28 ± 12
                        32 ± 14
                        29 ± 13

                        Disease durationa (mean ± SD)
                        10 ± 9
                        14 ± 11
                        11 ± 9

                        Time to diagnosticb (mean ± SD)
                        5 ± 7
                        5 ± 7
                        5 ± 7

a: difference between current age and age at symptom onset, b: difference
                     between age at diagnostic and age at symptom onset, CH indicates cluster
                     headache, SD indicates standard deviation

         </sec>
         <sec>
            <title>Factor Analysis of the CLCS and CSQ Questionnaires in the Whole Sample of CH
               Patients</title>

Results of factor analysis of the CLCS items are presented in <xref ref-type="table"
                  rid="t2">Table 2</xref>. Items with factor loadings >0.4 were retained for
               analysis except for item 1 (disease due to fate with no personal control) and item 12
               (influence of religion on disease progression). Two items were deleted because they
               failed to load consistently on any factor (item 5: influence of spouse and family on
               disease progression; item 8: influence of environmental pollution). Factor analysis
               yielded three varimax factors (factor 1: 9 items; factor 2: 3 items; factor 3: 3
               items) which together explained 51.8% of total variance. Relatively elevated
               Cronbach's α coefficients indicate good consistency of the resulting item sets for
               each factor.

               Table 2

                  <title>Factor Analysis of Items of the Cancer Locus of Control Scale (CLCS) in
                     Cluster Headache Patients</title>

                  <col align="right" width="5%"/>
                  <col align="left" width="50%"/>
                  <col align="center" width="15%"/>
                  <col align="center" width="15%"/>
                  <col align="center" width="15%"/>

                        CLCS items
                        Factor
                           loading

                        Factor
                           1
                        Factor 2
                        Factor 3

                        1
                        Disease due to fate and no personal control
                        -0.278
                        .
                        .

                        2
                        Personal ability to influence disease progression
                        0.636
                        .
                        .

                        6
                        Disease occurrence was due to lifestyle
                        0.713
                        .
                        .

                        9
                        Disease occurrence is patient's fault
                        0.626
                        .
                        .

                        10
                        Improved personal care can influence the disease
                        0.697
                        .
                        .

                        11
                        Events in patient's history promoted the disease
                        0.733
                        .
                        .

                        13
                        Improving lifestyle might influence the disease
                        0.623
                        .
                        .

                        14
                        Patient's personality may have promoted the disease
                        0.560
                        .
                        .

                        17
                        Disease occurrence was related to personal factors
                        0.698
                        .
                        .

                        4
                        Medical care can influence disease progression
                        .
                        0.783
                        .

                        15
                        Medical advice may help control disease progression
                        .
                        0.825
                        .

                        16
                        Struggling may influence disease progression
                        .
                        0.654
                        .

                        3
                        Pain Disease was due to God's will
                        .
                        .
                        0.900

                        7
                        God can surely influence disease progression
                        .
                        .
                        0.930

                        12
                        Religion may influence disease progression
                        .
                        .
                        0.315

                        Cronbach's α
                           coefficient
                        0.75
                        0.68
                        0.66

                        Percentage of total
                           variance explained by the factor
                        26.1
                        13.8
                        11.9

N = 71 patients (2 patients missing)

On the basis of items with high weight in factor 1, this factor can be interpreted as
               the perceived internal controllability (beliefs about personal and lifestyle
               influence on disease progression and about internal causes of the disease). Factor 2
               can be interpreted as the perceived medical controllability of pain (beliefs about a
               possible influence on disease progression with the help of medical care). Factor 3
               represents beliefs about the influence of religion on disease controllability.

Results of factor analysis of the CSQ items are presented in <xref ref-type="table"
                  rid="t3">Table 3</xref>. Factor extraction was carried out on the basis of five
               hypothesized principal components. The model indicated that the five varimax factors
               contributed to 64.9% of total variance.

               Table 3

                  <title>Factor Analysis of Items of the Coping Strategies Questionnaire (CSQ) in
                     Cluster Headache Patients</title>

                  <col align="right" width="5%"/>
                  <col align="left" width="50%"/>
                  <col align="center" width="9%"/>
                  <col align="center" width="9%"/>
                  <col align="center" width="9%"/>
                  <col align="center" width="9%"/>
                  <col align="center" width="9%"/>

                        CSQ items
                        Factor
                           loading

                        Factor
                           1
                        Factor 2
                        Factor 3
                        Factor 4
                        Factor 5

                        7
                        Not paying attention to pain
                        0.420
                        .
                        .
                        .
                        .

                        8
                        Doing as if pain did not exist
                        0.650
                        .
                        .
                        .
                        .

                        14
                        Going on as though nothing occurred
                        0.775
                        .
                        .
                        .
                        .

                        15
                        Engaging into a pleasant activity
                        0.758
                        .
                        .
                        .
                        .

                        17
                        Ignoring pain
                        0.671
                        .
                        .
                        .
                        .

                        2
                        Trying to think about something pleasant
                        .
                        0.781
                        .
                        .
                        .

                        10
                        Thinking about pleasant things in the past
                        .
                        0.846
                        .
                        .
                        .

                        11
                        Thinking about persons who are pleasant company
                        .
                        0.834
                        .
                        .
                        .

                        20
                        Thinking about pleasant activities
                        .
                        0.762
                        .
                        .
                        .

                        1
                        Trying to distance oneself from pain
                        .
                        .
                        0.739
                        .
                        .

                        5
                        Trying not to think about pain
                        .
                        .
                        0.524
                        .
                        .

                        6
                        Trying not to think that pain concerns the body
                        .
                        .
                        0.846
                        .
                        .

                        13
                        Trying to think that pain is outside the body
                        .
                        .
                        0.896
                        .
                        .

                        21
                        Doing as though pain was outside the body
                        .
                        .
                        0.703
                        .
                        .

                        3
                        It's terrifying and will never improve
                        .
                        .
                        .
                        0.746
                        .

                        9
                        Worrying all the time whether it will stop
                        .
                        .
                        .
                        0.495
                        .

                        16
                        Feeling that pain is no longer bearable
                        .
                        .
                        .
                        0.659
                        .

                        19
                        Feeling that going on is no longer possible
                        .
                        .
                        .
                        0.870
                        .

                        4
                        Praying God that it won't last
                        .
                        .
                        .
                        .
                        0.796

                        12
                        Praying for pain to disappear
                        .
                        .

                        .
                        0.660

                        18
                        Relying on faith in God
                        .
                        .
                        .
                        .
                        0.905

                        Cronbach's α
                           coefficient
                        0.69
                        0.87
                        0.81
                        0.73
                        0.80

                        Percentage of total
                           variance explained by the factor
                        20.8
                        16.7
                        11.7
                        8.2
                        7.5

N = 73 patients

On account of the five items allocated to factor 1, this factor may be interpreted as
               indicating attempts to ignore pain (by denying, disregarding or overlooking pain).
               The four items allocated to factor 2 appear to reflect diverting attention from pain
               by imagining scenes incompatible with pain (pleasant images or thoughts) or mental
               activity. The five-item set in factor 3 may be interpreted as reflecting attempts to
               reinterpret painful sensations (by conceiving and describing the painful sensations
               differently). The four items grouped in factor 4 and the three items in factor 5
               appear to represent tendencies to dramatize pain (catastrophizing thoughts and
               ideation, by focusing on the negative emotional component of pain) and to rely on God
               or religion or good luck to cure and end the pain (Praying and Hoping) for pain
               adjustment.

         </sec>
         <sec>
            <title>Relationships Between Perceived Internal Controllability of Pain and Emotional
               Distress, and Between the Components of Emotional Distress Themselves</title>

A positive relationship was observed between perceived internal controllability (as
               assessed by the summed score of the nine items of CLCS factor 1) and emotional
               distress (as assessed by the scores at the HAD global scale, the HAD anxiety and HAD
               depression/ anhedonia subscales, and the BDI) in the 73 study patients with either
               episodic or chronic CH (<xref ref-type="table" rid="t4">Table 4</xref>). Although
               generally weak, the correlation was highly significant, except for the correlation
               with anxiety alone (which closely neared significance, however: p = 0.0514). Thus, it
               appears that emotional distress increases with increasing level of perceived internal
               controllability of the disease.

               Table 4

                  <title>Relationships Between Perceived Internal Controllability of Pain and
                     Anxiety Alone, Depression/anhedonia, Depression Alone or Anxiety and/or
                     Depression, and Between the Components of Emotional Distress Themselves, in
                     Cluster Headache Patients</title>

                  <col align="left" width="30%"/>
                  <col align="left" width="20%"/>
                  <col align="center" width="17%"/>
                  <col align="center" width="17%"/>
                  <col align="center" width="17%"/>

                        Variable analyzed
                        versus:
                        Correlation coefficient
                        99% CI
                        Significance

                        Perceived internal controllability
                           of pain
                        Anxietya
                        0.229
                        -0.075;0.494
                        NS

                        Depression/anhedoniab
                        0.339
                        0.045;0.579
                        p = 0.003

                        Depressionc
                        0.336
                        0.041;0.576
                        p = 0.004

                        Anxiety and/or depressiond
                        0.339
                        0.045;0.579
                        p = 0.003

                        Anxietya
                        Depression/anhedoniab
                        0.417
                        0.135;0.636
                        p = 0.0002

                        Depressionc
                        0.375
                        0.086;0.606
                        p = 0.001

                        Anxiety and/or depressiond
                        0.829
                        0.706;0.904
                        p < 0.0001

                        Depression/anhedoniab
                        Depressionc
                        0.523
                        0.266;0.711
                        p < 0.0001

                        Anxiety and/or depressiond
                        0.854
                        0.745;0.918
                        p < 0.0001

                        Anxiety and/or depressionc
                        Depressionc
                        0.536
                        0.283;0.720
                        p < 0.0001

99% CI indicates confidence interval of the correlation coefficient at 99%
                     probability

a: as assessed by the score at the HAD anxiety subscale;
                        b: as assessed by the score at the HAD depression/anhedonia
                     subscale; c: as assessed by the score at the Beck Depression
                     Inventory (BDI); d: as assessed by the score at the HAD global
                     scale

N = 73 patients

Examination of individual data revealed that beliefs pertaining to internal causative
               attributions of the origin of the disease and to internal controllability constitute
               the greatest part of total CLCS score when the summed score at CLCS factor 1 is
               greater than 19 (possible range: 9-36), whereas the relative weight of these beliefs
               is less important when the factor-1 summed score is less than 12.

Inter-relationships between all anxiety and depression variables were also
               significant. Highest correlation coefficients were observed for the relationships
               between HAD global score and the scores at the HAD anxiety or HAD
               depression/anhedonia subscales (<xref ref-type="table" rid="t4">Table 4</xref>).

         </sec>
         <sec>
            <title>Comparison of the Groups of Patients with Episodic and Chronic Cluster
               Headache</title>

The comparison between patients with episodic and chronic CH was carried out on a
               subset of 32 patients (30 men and 2 women, 16 patients in each group). Mean age was
               44 years in both groups and patient groups did not noticeably differentiate by mean
               age at symptom onset (31 or 32 years), mean age at diagnostic (37 years in both
               groups), mean time to diagnostic after symptom onset (about 6 years in both groups),
               and mean disease duration (12 or 13 years). Perceived pain-related disability (HIT-6)
               was scored at 66 ± 5.6 for patients with chronic CH and 69 ± 6.2 for patients with
               episodic CH. Most patients were anxious (87% had a score of 8 or higher at the HAD
               anxiety subscale), half of them had anhedonia (53% had a score of 8 or higher at the
               HAD depression/anhedonia subscale), and two thirds were depressive (63% had a score
               of 4 or higher at the BDI).

There were only modest differences between the groups of patients with episodic or
               chronic CH with respect to emotional status, with only slightly (but not
               significantly) higher scores for anxiety in patients with episodic CH and for
               depression/anhedonia and depression in patients with chronic CH (<xref
                  ref-type="table" rid="t5">Table 5</xref>).

               Table 5

                  <title>Comparison of the Groups of Patients with Episodic or Chronic Cluster
                     Headache</title>

                  <col align="left" width="25%"/>
                  <col align="center" width="25%"/>
                  <col align="center" width="25%"/>
                  <col align="center" width="25%"/>

                        Patient attributes
                        Patients with episodic CH<break/>N = 16
                        Patients with chronic CH<break/>N = 16
                        Statistical significance*

                        Emotional status

                        Anxietya
                        11 ± 3
                        9 ± 4
                        NS

                        Depression/anhedoniab
                        7 ± 4
                        8 ± 5
                        NS

                        Depression severityc
                        7 ± 5
                        9 ± 8
                        NS

                        Perceived locus of control of
                           pain:

                        Internal control
                        19 ± 5
                        18 ± 5
                        NS

                        Medical control
                        9 ± 2
                        9 ± 2
                        NS

                        Religious control
                        6 ± 2
                        7 ± 3
                        NS

                        Perceived social support:

                        Availability
                        18 ± 11
                        12 ± 8
                        NS

                        Satisfaction with support
                        31 ± 5
                        26 ± 8
                        NS

                        Coping strategies:

                        Ignoring pain sensations
                        6 ± 2
                        8 ± 3
                        NS

                        Distraction
                        8 ± 3
                        7 ± 3
                        NS

                        Reinterpreting pain sensations
                        11 ± 4
                        8 ± 2
                        p = 0.007

                        Catastrophizing
                        11 ± 3
                        11 ± 3
                        NS

                        Praying and Hoping
                        6 ± 3
                        6 ± 3
                        NS

a: as assessed by the HAD anxiety subscale; b: as
                     assessed by the HAD depression/anhedonia subscale; c: as assessed by
                     the Beck Depression inventory (BDI); *: multiple regression analysis; CH
                     indicates cluster headache

There was no substantial difference between the two patient groups with respect to
               perceived control of the disease. On the other hand, perceived social support and
               satisfaction with support appeared somewhat higher for patients with episodic CH
               compared with those with chronic CH, but the between-group differences were not
               significant.

Regarding coping with pain, the two groups of patients did not differentiate on the
               strategies of Distraction, Catastrophizing, Ignoring pain sensations, and Praying and
               Hoping. Conversely, patients with episodic CH used significantly more frequently the
               strategy of Reinterpreting pain sensations compared with patients with chronic CH (p
               = 0.007). The type of CH (episodic or chronic) accounted for 21% of the variance of
               individual data for this strategy.

         </sec>
      </sec>
      <sec sec-type="discussion">
         <title>Discussion</title>

This study determined, in CH patients seen in an emergency headache center, the factor
            structures of a scale of perceived disease control (CLCS) and of a coping questionnaire
            (CSQ), and data were used to compare two subsets of patients with episodic or chronic
            CH. Factor analysis of CLCS identified three components corresponding to perceived
            internal controllability of the disease, medical controllability, and religious
            controllability, respectively, and these components differ from the three subscales
            described for the original scale (internal/external controllability of disease
            progression, internal/external attribution of the origin of the disease, religious
            controllability). Perceived internal controllability was significantly correlated with
            depression variables (BDI, HAD depression/anhedonia subscale, HAD global scale). Factor
            analysis of CSQ revealed a similar item allocation to that previously described for the
            French version of the questionnaire, with only minor differences in individual item
            allocation to the factors. Comparison of subsets of patients with episodic or chronic CH
            did not show significant differences in emotional status, perceived locus of control of
            the disease and perceived social support or coping strategies, except for the strategy
            of Reinterpreting pain sensations which was more frequently used by patients with
            episodic CH than chronic CH.

Of the three CLCS components identified by factor analysis in CH patients, the nine-item
            component groups together items relating to both beliefs about personal responsibility
            in disease progression (through personal efforts and changes in lifestyle) and beliefs
            about internal attributions of the origin of the disease (lifestyle, patient's history
            or personality or other personal factors). This component corresponds to two distinct
            subscales in the original CLCS structure. Conversely, the second component identified
            contains three items related to medical support and willingness to control the disease,
            and may thus be interpreted as reflecting 'fighting spirit' (<xref ref-type="bibr"
               rid="r40">Watson et al., 1990</xref>). The three items of the second component
            identified in CH patients are also allocated to two different subscales (internal and
            external locus of control subscales) in the original CLCS structure. Finally, the
            three-item third component ('religious control') identified in CH patients matches the
            corresponding original CLCS subscale.

Different reasons may potentially account for the differences between the factor
            structure observed in our patient sample and the original CLCS subscales. One of them
            may be the number of questionnaires patients were administered. Although the CLCS
            appeared well understandable to patients, some of them seemed to get confused when asked
            to distinguish between the causes and consequences of the disease and about links with
            lifestyle. Generally speaking, patients appeared to acknowledge either some
            responsibility in the disease or no responsibility at all. This may explain the observed
            grouping in a single component of CLCS items relating to internal/external locus of
            control or causative attributions. Similarly, responses to items pertaining to pollution
            and role of close relations were generally dichotomized and were excluded from analysis.
            Association of medical support with definite willingness to fight against the disease
            may originate, in the particular case of CH patients, in the efficacy of injectable
            sumatriptan for the control or ajustment of attacks.

The CLCS factor 1 identified in CH patients contained chiefly items relating to internal
            control (except item 1–role of fate–which in fact falls on the negative side of the
            belief). Of the nine items of factor 1, five pertain to internal attribution of the
            origin of the disease, and three to personal efforts required to control disease
            progression. High perceived internal control over the <italic>cause</italic> of the
            illness is associated with an 'anxious preoccupation' about the disease (<xref
               ref-type="bibr" rid="r40">Watson et al., 1990</xref>) and may ultimately lead to
            depression. In fact, correlations between factor 1 summed score and measures of
            depression (HAD depression/anhedonia subscale, BDI score) were highly significant in CH
            patients, while the correlation with anxiety (HAD anxiety subscale) approached
            significance. Moreover, all measures of depression and anxiety were found to be
            significantly inter-correlated, confirming that anxiety and depression are linked in
            pain patients.

CSQ factor structure was analyzed on an <italic>a priori</italic> basis of five
            cognitive and behavioral pain coping strategies. Three main factors (cognitive coping
            and suppression, helplessness, and Diverting attention or Praying) were initially
            reported by the authors of the instrument (<xref ref-type="bibr" rid="r33">Rosenstiel
               & Keefe, 1983</xref>), but varied numbers of factors (5, 6 or 7 factors) were
            subsequently identified with the original 48-item version of the questionnaire (<xref
               ref-type="bibr" rid="r36">Swartzman, Gwadry, Shapiro, & Teasell, 1994</xref>;
               <xref ref-type="bibr" rid="r31">Riley & Robinson, 1997</xref>; <xref
               ref-type="bibr" rid="r32">Robinson et al., 1997</xref>). The five-factor structure
            retained for analysis in the present study corresponds to the five-factor structure
            previously observed for the 21-item French version of the questionnaire (<xref
               ref-type="bibr" rid="r17">Irachabal, 2002</xref>). Absence of self-statements in the
            French version does not appear to alter the factor structure of the scale, although
            negative self-statements were reported to be more predictive of psychosocial functioning
            than pain beliefs in chronic pain patients (<xref ref-type="bibr" rid="r35">Stroud,
               Thorn, Jensen, & Boothby, 2000</xref>). In the present study, factor allocation
            of two items differed from previous results with the French CSQ version: item 5 (Trying
            not to think about pain) was allocated to the reinterpretation strategy (instead of
            Ignoring pain sensations) and item 15 (Engaging into a pleasant activity) to the
            Ignoring pain sensations strategy (instead of Distraction). The other strategies used by
            CH patients appeared to contain the same items as those noted in the previous French
            study in patients with other painful pathologies (<xref ref-type="bibr" rid="r17"
               >Irachabal, 2002</xref>).

Regarding the comparison of the two subsets of patients with episodic or chronic CH,
            analysis revealed no significant difference in emotional status, perceived
            controllability of the disease (internal, medical, religious) and perceived social
            support. The only significant difference between the two types of CH concerned the use
            of the Reinterpreting pain sensations strategy (more frequently used by patients with
            episodic CH). In contrast to what might have been expected, the absence of difference in
            perceived controllability indicated a similar degree of helplessness leading to
            hopelessness between the two groups of patients who also shared similar beliefs about
            the role of medical attention.

Nevertheless, some noticeable trends were detectable. Anxiety seemed slightly higher in
            patients with episodic CH, whereas depression seemed slightly higher in those with
            chronic CH. Drawing a parallel with migraine, uncertainty about the possible occurrence
            of attacks may be hypothesized to generate more anxiety in patients with episodic CH,
            whereas protracted periods of attacks may cause more depression in patients with chronic
            CH. Patients with episodic CH seemed to benefit more from social support. Slightly more
            patients with chronic CH used the Ignoring pain sensations strategy. These differences
            did not reach significance, however, probably due to the limited size of each patient
            subset (16 patients per group) and relatively large inter-individual variability. It
            needs also to be recalled that data differences between groups were analyzed after
            controlling for disability. Nevertheless, although limited in size and number, the
            differences observed between the two types of CH suggest a more 'active' profile for
            patients with episodic CH (more anxiety, greater reliance on social support, more
            reinterpretation of pain sensations) and a more 'passive' profile for patients with
            chronic CH (more depression, less social support, more attempts to ignore pain).

One possible limitation of the study is that it was conducted among CH patients seen in
            an emergency headache center, which may have influenced in some way the characteristics
            of the patient sample. Another limitation may be the small number of patients included
            in the subsets of patients with episodic or chronic CH (a consequence of the need for
            obtaining well-matched patient subsets with respect to patients' characteristics).
            Furthermore, a single instrument was used for the exploration of coping strategies. In
            fact, CSQ only explores <italic>cognitive</italic> coping strategies but let aside
               <italic>behavioral</italic> coping strategies. Complementary use of Chronic Pain
            Coping Inventory (<xref ref-type="bibr" rid="r18">Jensen, Turner, Romano, & Strom,
               1995</xref>; <xref ref-type="bibr" rid="r15">Hadjistavropoulos, MacLeod, &
               Asmundson 1999</xref>), which is more strongly oriented to functioning and behavioral
            strategies of coping with pain, would perhaps have contributed to a more distinct
            differentiation of the respective profiles of episodic and chronic CH patients. However,
            time constraints forced to limit the number of questionnaires administered to study
            patients (an average of two hours was required to administer the whole battery of study
            questionnaires, taking account of resting intervals and time for medical support and for
            advice and possible referral). On the other hand, a possible strength of the study may
            be the relatively short duration of data collection (nine months), due to unique
            recruitment facilities (more than 8 000 patients are seen in the Emergency headache
            center in a year, of whom about 400 are CH patients), which ensures relative homogeneity
            of measures.

In conclusion, this study showed that the factor structure of perceived disease
            controllability in CH patients may be somewhat different from that reported for other
            painful pathologies. This difference may be linked with specificities of the disease,
            especially the excruciating intensity of CH pain. However, the coping strategies used by
            CH patients do not seem to diverge noticeably from other painful diseases. Finally,
            comparison of subsets of patients with episodic or chronic CH suggested a more passive
            profile for those with chronic CH and this deserves substantiation in further studies
            involving larger groups of patients.

      </sec>

      <front-stub>

            <subj-group>
               <subject>Oral Presentation</subject>
            </subj-group>

         <title-group>

A Cross-Cultural Study of the Positive and Negative Aspects of Being
               LGB

         </title-group>
         <contrib-group>
            <contrib contrib-type="author">
               <name name-style="western">
                  <surname>Strizzi</surname>
                  <given-names>Jenna Marie</given-names>
               </name>
               <xref ref-type="aff" rid="aff1-1">
                  a
               </xref>
            </contrib>
            <contrib contrib-type="author">
               <name name-style="western">
                  <surname>Agis</surname>
                  <given-names>Inmaculada Fernandez</given-names>
               </name>
               <xref ref-type="aff" rid="aff1-1">
                  a
               </xref>
            </contrib>
            <contrib contrib-type="author">
               <name name-style="western">
                  <surname>Rodríguez</surname>
                  <given-names>Raquel Alarcón</given-names>
               </name>
               <xref ref-type="aff" rid="aff1-1">
                  a
               </xref>
            </contrib>
            <contrib contrib-type="author">
               <name name-style="western">
                  <surname>Carreño</surname>
                  <given-names>Tesifon Parrón</given-names>
               </name>
               <xref ref-type="aff" rid="aff1-1">
                  a
               </xref>
            </contrib>
            <aff id="aff1-1">
               [a]University of Almería, SPAIN</aff>
         </contrib-group>
         <author-notes>
            <corresp id="cor1-1">
               <email xlink:href="jenna.strizzi@gmail.com" xlink:type="simple"
                  >jenna.strizzi@gmail.com</email>
            </corresp>
         </author-notes>
      </front-stub>

The final aim is cross-cultural study on the positive and negative aspects of being gay,
            lesbian and bisexual in the United States and Spain. The authors seek to repudiate the
            tendency to study non-heterosexual sexual orientations from a marked pathological
            viewpoint and create a method which more adequately represents the everyday experiences
            of this population. 10 scales were selected, all which had been validated in English by
            other authors. All those not previously validated in Spanish were translated and
            validated through this study. Positive aspects are operationally defined as social
            support, self-esteem, social activism and justice, and sexual satisfaction. While
            negative aspects are defined as: violence, social stigma, homo/bi negativity, and
            depression (which was measured through subjective happiness). The validation of the New
            Sexual Satisfaction Scale in Spanish marks the first scale in this language to measure
            sexual satisfaction in the LGB population. While negative aspects, such as violent
            incidents, were suffered by nearly 15% of participants in both countries, almost 80%
            reported having been discriminated for their sexual orientation in the past year.
            Positive aspects including social support, self-esteem, and subjective happiness were
            quite high suggesting minority resilience.

   <back>
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      <bio>

<bold>Dominique Valade</bold>, M. D., Ph. D., is a neurologist. He has created "The
            Emergency Headache Centre of the Paris hospital-Lariboisière". He is actually the
            President of the European Headache federation.

      </bio>
      <bio>

<bold>Frédéric Fontenelle</bold> is a psychologist. He practices cognitive and
            behavioral therapies.

      </bio>
      <bio>

<bold>Caroline Roos</bold>, M. D., is a neurologist at the Hospital Lariboisière in
            Paris.

      </bio>
      <bio>

<bold>Céline Rousseau-Salvador</bold> Ph. D., is a psychologist. She practices cognitive
            and behavioral therapies.

      </bio>
      <bio>

<bold>Anne Ducros</bold>, M. D., Ph.D., is a neurologist in "The Emergency Headache
            Centre of the Lariboisiere Hospital" in Paris and the Pr elect of Neurology in the
            faculty of medecine in Montpellier.

      </bio>
      <bio>

<bold>Stéphane Rusinek</bold>, Ph. D., is a professor of psychology at the University of
            Lille (PSITEC Laboratory).

      </bio>
   </back>