Headache sufferers' drawings reflect distress, disability
and 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 Zealand
bThe University of Texas, Austin, TX, USA
cDartmouth College, Hanover, NH, USA
Received 15 February 2008
Objective: Drawings have recently been used with patients
with heart problems to assess their perceptions of their illness.
This study aimed to investigate whether drawings could be a
useful way to assess headache patients' perceptions of their
headaches and their reactions. Methods: In a cross-sectional
study, 65 university students who experienced persistent head-
aches were asked to draw a picture of how their headaches
usually 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. Associations
between drawings, illness perceptions, mood, and health out-
comes were assessed. Results: Twenty-seven people drew an
external force to the head and these people had greater ratings of
average pain and were more likely to attribute their headache to
stress. Darker drawings were associated with greater emotional
distress and lower vitality. Larger drawing size was associated
with perceptions of worse consequences, worse symptoms, worse
emotional representations, lower vitality, higher pain, and more
days 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 and
distress. People draw how they see themselves experiencing their
headache and often include expressions and reactions. The
inclusion of force to the head, darker drawings, and larger
drawings are associated with worse perceptions of the headache
and higher pain. Drawings may be a useful way for clinicians to
understand patients' experience of pain.
© 2009 Elsevier Inc. All rights reserved.
Keywords: Drawings; Headache; Illness perceptions; Pain
Recent work has shown that patients' drawings of their
illness can reveal their perceptions about the physiology
and nature of their illness. Myocardial infarction patients'
drawings of their heart captured the extent to which they
believed their heart had been damaged, which predicted
speed of return to work and self-reported recovery .
Furthermore, patients whose drawings of their heart
increased in size over the recovery period reported greater
anxiety and poorer recovery at follow-up than those whose
drawings got smaller , suggesting that drawing size
can indicate the extent to which the patient is thinking
about the illness. This is supported by other research that
has shown that larger sizes of heart failure patients'
drawings of their heart are associated with higher levels of
cardiac anxiety .
Using drawings as a technique to assess patients'
perceptions of an illness relies on patients' abilities to
Journal of Psychosomatic Research 66 (2009) 465–470
⁎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: email@example.com (E. Broadbent).
0022-3999/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
visualize the affected organ. The heart is a well-known part
of the body and more easily drawn than more obtuse organs
such as the pancreas or spleen. In this study, we were
interested in whether drawing could be a useful method to
assess perceptions in another part of the body, the head.
Headaches are commonly experienced in the general
population, with about 30% of the Western population
experiencing at least one headache per year . Annually
in the UK, about 3 million days are taken off work due to
headache. Research has shown that patients' illness
perceptions are important in headache patients. Headache
patients who believe that their condition will last a long
time and that it has severe personal consequences are more
likely to be depressed . The most common attributions
for chronic daily headache are psychological, such as stress
Previous work with children suggests that drawings may
be a useful way to assess perceptions in headache patients.
Unruh et al.  asked children to draw their pain. Thematic
analysis revealed themes including actions and instruments
causing pain, personification of the pain, physiological
representation of the pain, perceptual disturbance associated
with the pain, abstract representation of the pain, and
location of the pain. The content of children's headache
drawings can reliably differentiate migraine from non-
migraine headaches, and changes in drawings over time
reflect clinical improvements [7,8]. Children who have
migraines tend to include sharp objects, while those with
tension-type headaches include compression, and those
with somatoform disorders sometimes include whirls in
the head .
Chronic pain patients are often asked to draw the location
of their pain onto provided outlines of the body, and these
drawings can indicate unusual diseases or show changes in
experienced pain over time . Asking patients to draw
more general pictures of how they experience their pain
(without any outlines) may reveal additional information
about the patients' perceptions.
In this study, we aimed to investigate adults' perceptions
of their headaches using drawings as an assessment method.
We were interested in studying how features of the drawings
were associated with individuals' illness perceptions, levels
of pain, disability, and number of doctor visits. From our
previous work, we hypothesized that bigger drawings would
be associated with poorer illness perceptions and poorer
physical and mental functioning.
This cross-sectional study was conducted at the Uni-
versity of Texas, Austin. Sixty-five introductory psychology
students were recruited for the study by online invitation.
The only restrictive criteria were that the student had to
experience persistent headaches. The study was approved by
the Institutional Review Board.
Participants were asked to draw their headache as it most
commonly affected them. The instructions were adapted
from previous studies with heart attack patients and read,
“While many patients suffer from headaches, headaches are
rarely experienced by different people in the same way—in
location, intensity and the nature of the pain. As a result,
people picture their headache in different ways. In this
project, we are interested in the way you see your headache.
We would like you to draw your image of your headache. We
are not interested in your drawing ability—a simple sketch is
fine. We are interested in how you see your headache. In the
space below, please draw your headache as it most
commonly affects you.” These instructions were printed on
an otherwise blank A4 size piece of paper as part of a larger
questionnaire. Participants completed the form with a
The questionnaire included the Brief Illness Perception
Questionnaire (Brief IPQ) , a nine-item scale that
assesses participants' views of the timeline, consequences,
causes, symptoms, personal control, helpfulness of treat-
ment, concern, emotional reactions, and understanding of
their headaches. The vitality and mental health scales of the
SF36 were included . The questionnaire also included
two questions asking participants to rate the worst pain and
average pain from their headaches on scales from 1 (no pain)
to 10 (extreme pain). Participants reported the number of
doctor visits they had made in the past year, as well as the
number of days in the past month they restricted their
activities due to headaches.
The drawings were analysed by laying out all the pictures
and identifying common aspects of the drawings that
differentiated between them. The four raters were health
psychology academic staff and postgraduate students. These
aspects were recorded and the drawings were subsequently
scored along these dimensions. Scoring was performed as a
collective group process with high agreement within the
group; κ statistic was not calculated. Similar to previous
work, we measured the size of the drawings in millimetres
from top to bottom and from side to side [2,3].
Previous research with heart attack patients found
correlations between drawings and illness perceptions
ranging between r=.33 and r=.45. A two-tailed power
analysis with r=.35, α=.05, and power=.80 showed that
61 participants were required .
Data were analysed using SPSS (version 14). The
normality of the data was checked using Kolmogorov–
Smirnov tests, and nonparametric statistics were used where
data were not normally distributed. Vertical and horizontal
size of drawings, control, identity, vitality, and mental health
were normally distributed, and Pearson's r was used for
correlations between these items; in all other correlations,
Spearman's ρ was used. Differences between groups were
analysed using Mann–Whitney and Kruskal–Wallis tests.
466 E. Broadbent et al. / Journal of Psychosomatic Research 66 (2009) 465–470
What did patients draw?
Some examples of headache drawings are shown in Fig. 1.
From visual inspection, a number of differences could be
identified between patients' drawings. First, there were
differences in the location of pain drawn in the head (e.g.,
in the temples or the back of the head) and in the number of
places pain was drawn. Second, drawings differed in the
nature of the pain drawn; there was a large group of people
who drew their pain as an external force on their head, such as
a hammer or dagger, while others drew their pain as an
entirely internal process within the head, such as a simple
shaded area. Third, patients differed in the intensity of the
drawings of pain; some patients used thick heavy pen strokes
while others used very light pen strokes. Lastly, some patients
drew expressions of emotions on their face while others drew
no emotional expressions. We classified drawings into
categories based on the number of pain areas drawn, whether
an external force was drawn, and whether facial expressions
were drawn. To measure the intensity of pen stroke, drawings
were scanned into photoshop and analysed using Image J
software mean greyscale. Analyses were performed to see
whether differences in the drawings based on these variables
were associated with illness perceptions and health outcomes,
as described below.
Number of pain areas
In 9% of drawings, no particular pain area could be
identified, 34% of drawings contained one area of pain, 29%
Fig. 1. Examples of people's drawings of their headaches.
467 E. Broadbent et al. / Journal of Psychosomatic Research 66 (2009) 465–470
had two areas of pain, and the remaining 28% had three or
more pain areas. There were no differences between these
groups on any illness perceptions or other outcomes.
Twenty-seven people (41.5%) drew external force to their
head (such as a hammer). Mann–Whitney tests showed that
those who drew external force in their drawings rated their
average pain as worse (mean=6.08, S.D.=1.29) than those
who did not draw external force (mean=5.16, S.D.=1.59; Z=
Thirty-two participants attributed their headaches to
stress, and 33 attributed their headaches to other factors
such as lack of sleep, dehydration, or sinus problems. A
greater proportion of people who drew external force on their
drawings attributed their headaches to stress (19/27) than
other people did (13/38; χ2=8.29, P=.004).
Facial expressions were evident in 43 of the 65 drawings
(66%). There were no differences in illness perceptions or
other outcomes between those who drew facial expressions
and 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.
Larger size was associated with perceptions of worse
consequences, worse symptoms, worse emotional represen-
tations, lower vitality, higher pain, and more days of
Because the SF36 mental health scale includes a
combination of anxiety, depression, calmness, and happiness
items, we further investigated the association between
drawing size and mental health using these individual
items. The item “how often in the past 4 weeks have you
been 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 the
past 4 weeks have you felt so down in the dumps that nothing
could cheer you up?” was also associated with both vertical
(Spearman's ρ=.32, P=.01) and horizontal size (Spearman's
ρ=.25, P=.04). The other items were not significantly
associated with drawing size.
We were also interested in how people's illness percep-
tions assessed using the Brief IPQ were associated with
health outcomes; these correlations are shown in Table 2.
Higher pain ratings were associated with higher conse-
quences, longer timeline, lower personal control, higher
identity, and higher concern. More days restricted were
associated with higher consequences and higher concern.
More doctor visits were associated with higher consequences
and higher control perceptions. Lower vitality was asso-
ciated with higher consequences and higher emotional
representations. Poorer mental health was associated with
higher emotional representations.
People's drawings of their headaches illustrated how they
experienced their pain in a graphic way. The drawings
Associations between the size of patients' drawings, illness perceptions, and health outcomes
Vertical size of drawing
Horizontal size of drawing
Visits to the doctor
468E. Broadbent et al. / Journal of Psychosomatic Research 66 (2009) 465–470
depicted the quality of the pain (as a stabbing dagger or
heavy pressure) and the location of the pain, as well as
emotional reactions to the pain through facial expressions
and behavioral reactions, such as the desire to sleep or rub
the head. The depiction of an external force to the head was
common, and people who drew this reported high ratings of
pain and were more likely to attribute their headache to stress
than others. It could be that these people see stress as an
external force, acting upon them physically and mentally to
Larger drawings were associated with worse outcomes,
including perceptions of greater consequences, higher
emotional representations, worse symptoms, worse pain,
and more days restricted. This is the first study to look at the
relationship between drawing size and positive emotions and
to find out that smaller drawings were associated with greater
happiness and vitality. Drawing size may reflect the
importance of the headaches to the individual.
The use of ink in the drawings was also indicative of how
they experienced their headache. People who drew darker
drawings reported being more emotionally affected by their
headaches and reported lower vitality. Ink use may reflect a
more unconscious expression of the person's feelings
towards the headaches. Future research needs to further
investigate whether ink use varies within subjects for
drawings of different objects.
It is useful to compare these findings with earlier studies.
The type of lines drawn is a variable that has been used
before in psychodynamic analyses , but we have not
previously used this variable in our previous work with heart
patients. Heavy use of ink was particularly noticeable in
headache drawings compared to heart attack patients'
drawings. External force to the affected organ was much
more common in headache patients' drawings than in heart
attack patients' drawings. This is despite the common
description of a heart attack as crushing chest pain and the
common stress attribution. However, the pain would have
subsided by the time the patients were asked to draw their
hearts. Heart attack patients were more likely to draw muscle
tissue damage, which is something that common headaches
are not usually associated with. The finding that larger
drawings were associated with poorer outcomes is congruent
with the heart attack research.
The study also backs up previous findings that
headache sufferers' illness perceptions are associated
with health outcomes . Of particular relevance for
health care professionals is that higher control perceptions
and higher consequence perceptions were associated with
more doctor visits.
This study further demonstrates that asking patients to
draw their illness is a useful technique to assess how people
think about their illness. The study extends the previous use
of drawings to assess illness perceptions from diseases of the
heart to the head. Drawing size has again been shown to be
an important variable. Other features of the drawings appear
to differ between illnesses, such as the depiction of tissue
damage on the heart or external force to the head; hence,
these features must be analysed based on the particular
illness studied. Further research could investigate the use of
drawings to assess the perceptions of patients with other
types of pain, such as back pain, and investigate how these
perceptions predict recovery.
This study has several limitations. The inclusion criteria
of persistent headache could have been better defined. It
would have been useful to include a screening tool for
migraine, a standard headache severity measure, and
assessment of comorbid health complaints. It would also
have been useful to collect demographic information. Some
migraine patients experience macrosomatognosia or micro-
somatognosia, in which parts of the body can be perceived
as overly large or small. It would be interesting to
investigate these perceptions in future work.
These findings suggest that this method of eliciting
drawings may be a useful tool for health practitioners to
assess patients' perceptions of their headache. Drawings may
be especially useful when there are language barriers
between the patient and health professional. Drawings
offer a very open way for the patients to express their
views and may reflect feelings and perceptions outside the
range of some questionnaires. Components of the drawings
may give the practitioner an insight into the patients'
experience of their pain and provide potential avenues to
explore. The drawing of heavy pressure to the head, for
example, may be a good starting point for discussion about
the types of stress the patients feel they are under and how
they might reduce this.
The association between illness perceptions and health outcomes
Number of doctor visits
469 E. Broadbent et al. / Journal of Psychosomatic Research 66 (2009) 465–470
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