Minor Stressful Life Events (Daily Hassles) in Chronic Primary Headache: Relationship with MMPI Personality Patterns.
G. De Benedittis and A. Lorenzetti
Reprint requests to: Giuseppe De Benedittis, M.D., Pain Research & Treatment Unit, Institute of Neurosurgery, University of Milan, 35, via F. Sforza, 20121 Milano, Italy Accepted for publication April 25, 1992 SYNOPSIS
This study investigated the relationship between minor life events (i.e. daily hassles) and personality patterns from selected scales of MMPI in the persistence of primary headache in 83 patients. Comparisons between headache subgroups indicated that tension-type headache patients are much more likely than those with migraine to have experienced high level of microstress (hassles density),with mixed headache in between. Tension-type headache patients reported higher MMPI scores on scales 1, Hypochondriasis (somatic concern), scale 3, Hysteria (denial) and scale 7, Psychasthenia (anxiety), but not on scale 2 (Depression), than migrainous patients. In addition, individuals with high level of microstress appeared to be more depressed and anxious than low-stress headache patients, scoring significantly higher on MMPI scales 2 (Depression) and 7 (Psychasthenia). As no significant differences due to sex, age, headache history and status, except for the headache density (i.e. severity x frequency) appeared, it is likely that high-stress levels are due, at least in part, to greater density of pain, rather than to discrete headache syndromes. Our findings support the notion that depressed mood and anxiety may account for a third intervening variable in the relationship between chronic headache and life stress. Key words: Headache; Stress; Life events; Daily hassles; MMPI. Abbreviations: HS Hassles Scale, VAS Visual Analogue Scale IPQ Italian Pain Questionnaire, MPQ McGill Pain Questionnaire, PPI Present Pain Intensity, PRI-T Pain Rating Index-Total, HI Headache Index, HD Headache Density (Headache 1992; 32:330-332) INTRODUCTION
Chronic primary headache is by far the most common chronic pain syndrome which, due to the complex multifactorial aetiology1, has been shown to be often associated with emotional stress.2-4 In fact, stressful life events have been implicated in the onset, exacerbation and maintenance of headache.5-9 In addition to the major life events approach, Lazarus and his group10-14 have recently focused attention upon the great adaptational significance of the relatively minor stresses, or daily "hassles", that characterize everyday life and may be a better approach to the prediction of health outcomes than the usual life events approach.12 The observed association between stressful life events and primary headache may be spurious, however, due to a "third variable", that might be correlated with both life events and headache.15 Personality traits are such a likely intervening variable. Despite the clinical relevance of the problem, the relatively few attempts to find psychological test patterns which are characteristics of headache patients have been controversial and generally disappointing.16-20 Headache patients, particularly tension-type and mixed headache sufferers, consistently show elevated scores on neurotic scales, but it is seldom clear whether these abnormalities precede the headache or are the consequence of it. Moreover, significant differences among headache diagnostic groups are rarely seen, when other variables such as age, sex, frequency, duration and severity of pain are controlled.18 In a previous study investigating the relationship between minor stressful life events (daily hassles) and the persistence of primary headache,9 using both normative group ratings and self-report ratings, we have shown that relatively minor life events, but not major life events, are significantly associated with the persistence of primary headache. Since probably no person leads a hassle-free life, the impact of hassles must depend not only on the chronically high frequency of hassles but also on its content and meaning in the person's life as well as on personality traits and coping skills.12 The aim of the present study was therefore to extend our previous investigation to evaluate the relationship of daily hassles with personality traits as "event mediators" in the persistence of primary headache. MATERIAL AND METHOD
Subjects. Eighty-three patients admitted consecutively to the Pain Research & Treatment Unit, Institute of Neurosurgery of the University of Milan, with a diagnosis of chronic primary headache participated in the study. Fifty-eight were females (69.9%) and twenty-five were males (30.1%). Their age ranged from 18 to 60 years (mean ± SD: 37.4 ± 11.7).
To be considered eligible for the study, headache patients were required to meet the following inclusion criteria: (a) ages 18-60 inclusive; (b) headache duration of at least two years (mean duration ± SD = 14.7 ± 10.6 years); (c) minimum frequency of four attacks per month (mean frequency ± SD = 16.3 ± 10.4). Headache subgroups, diagnosed according to the Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain of the Headache Classification Committee of the International Headache Society21, included: (a) chronic tension-type headache (n=35); (b) migraine (n=27); (c) mixed headache (n=16) and (d) cluster headache (n=5)(. An age, gender and socioeconomic status matched sample of fifty-one subjects was chosen for the control group. Thirty-three were healthy, pain-free subjects, while eighteen were neurosurgical patients, with negative headache history. Thirty-one subjects were females (60.8%), twenty were males (39.2%). The age ranged from 24 to 55 years (mean age ± SD = 32.6 ± 6.5). Procedures. All the patients were in the "waiting list" for specific treatment at the Pain Research & Treatment Unit of the University of Milan. In order to obtain reliable baseline data, during the study patients were not allowed the use of prophylactic drugs, but only the occasional use of symptomatic ones (i.e. in case of unbearable headache). Symptomatic drug abuse in migraine patients (e.g. ergotamine compounds) was not allowed, in order to avoid rebound-headache. A cohort study-design was adopted. Each participant received several measures assessing different dimensions of stressful life events (major life events, minor daily events) and of pain status. (1) Minor Life Events. In order to evaluate the role of daily hassles (i.e. repeated, "minor" ongoing stresses and strains of daily living) on the persistence of headache, a prospective study design was adopted. Headache patients and control group were given The Hassles Scale.12 The Hassles Scale (HS)12 is a questionnaire consisting of 117 items, hassles, which a person could have experienced in the previous month. In addition, respondents rated each hassle for how disturbing it was on a 3-point scale ranging from "not much" to "very much". The HS was administered once a month for 3 consecutive months as a part of a 3-month period longitudinal study. Two summary scores for each HS were generated for analysis: (a) frequency, a simple count of the number of items checked, which could range from 0 to 117; (b) density, which was the monthly mean severity (i.e. frequency x severity rating) reported by participants for all items checked. (2) Personality Traits. The Minnesota Multiphasic Personality Inventory (MMPI) was utilized to examine clinical correlates of behavior.22 This questionnaire contains 550 true and false items designed to give information regarding an individual's current personality profile. For the purpose of this study, scales examined in headache patients were scale 1, Hypochondriasis (symptom preoccupation), scale 2, Depression, scale 3, Hysteria (denial) and scale 7, Psychasthenia (anxiety). These scales were chosen because they have been shown to be important predictors of headache subgroups and to provide information regarding the presence of depression or "masked depression".17-19,23 Raw MMPI scores were converted to T scores using the Swenson et el.24 norms for 50,000 medical patients. All scores were of K-corrected values. (3) Pain Status. Baseline assessment of headache frequency, severity and quality was made by means of the following indices: (a) the headache history (years); (b) the Headache Index (HI), i.e. number of headache attacks per month, monitored by a daily pain diary; (c) the Headache Density, (HD), i.e. severity of attack times frequency. The severity of attack was rated on a 1-3 scale, with respect to pain intensity and disability (degree 1, mild, undisturbing attack; degree 2, moderate, disturbing attack; degree 3, severe, incapacitating attack); (d) the Visual Analogue Scale (VAS) and (e) the Italian Pain Questionnaire (IPQ),25 the national analogue of the McGill Pain Questionnaire (MPQ).26 The following indices were taken into consideration: (a) the 5-point Present Pain Intensity (PPI) scale, which measures the overall present pain intensity; (b) the Pain Rating Index - Total (PRI-T), which is a global measure of the multidimensional experience of pain. (4) Statistical analysis. The following procedures were used for the statistical analysis: (a). Frequency calculations including arithmetic mean, median, mode, standard deviation and standard error. (b). Differences between and within groups/subgroups of dependent variables were analyzed by the ANOVA (multiple comparisons). Significant effects were further analyzed using the Tukey's post hoc test. (c). Associations between independent and dependent variables were measured by correlation analysis (Pearson product-moment correlation ). RESULTS Minor Life Events. Daily hassles density and headache subgroups. As the correlations between the frequency and density of hassles were remarkably high (r= 0.76, p < 0,001), subsequent analyses were performed only for the density scores, which better reflect the perceived impact of hassles on individual daily life patterns. Low, medium and high scorers were determined by using median splits for the bottom, middle and top thirds of distribution. Low scorers reported an average of 58 hassle density scores, those with medium scores were affected by an average of 96, and those with high scores reported an average of 188 scores over the 3 month period study. Table 1 shows that tension-type headache patients (TTH) are much more likely than those with Migraine (MIG) to have experienced high level of stress (hassles density), with mixed headache patients (MIX) in between (X2 = 9.32, p < .025). Table 1 Daily Hasses Density Low Medium Cluster Headache 1 (4.5%) 2 (9.5%) Migraine 10 (45.5%) 14 (35%) Mixed Headache 5 (22.7%) 6 (15%) Tension-type h. 6 (27.3%) 18 (45%) N= 22 (100%) 40 (100%) Syndromes
High 2 (5%) 3 (14.3%) 5 (23.2%) 11 (52.4%) 21 (100%)
Daily hassles density, gender, age and pain-related variables. There were no significant sex-related differences in daily hassles magnitude. The influence of age, headache history and status (headache index and density, VAS, PPI, PRI-T) on the above mentioned measures was also examined by means of separate ANOVA. Statistically significant differences were found for the
headache density variable only, with high-density daily hassles patients reporting higher headache density than medium (p < .05) and low density subjects (p < .01). No statistically significant differences were found for the remaining variables. MMPI. MMPI. Headache patients vs controls. The influence of headache status on MMPI data was examined by means of a 2 (groups: CPH patients, headache-free controls) x 13 (MMPI scales: (3 validity, 10 clinical) analysis of variance (ANOVA). The ANOVA indicated significant main effects for the groups: F(25, 1754= 37.30, p < .001). The post-hoc analysis (Tukey's test) showed significant differences on scales 1, Hypochondriasis (p< .01), scale 2, Depression (p< .01) and scale 3, Hysteria (p < .01), with headache patients scoring significantly higher than controls. MMPI and diagnostic categories. The influence of diagnostic categories in the headache population on MMPI selected scales was examined by means of a 3 (groups: tension-type headache, TTH; mixed headache, MIX and migraine, MIG) x 4 MMPI scales (scale 1, Hypochondriasis; scale 2, Depression; scale 3, Hysteria: scale 7, Psychasthenia) split-plot ANOVA. Cluster headache category was not considered for statistical analysis because of the paucity of the sample (n=5). The post-hoc analysis (Tukey's test) showed that TTH patients scored significantly higher than MIG patients on scale 1, Hypochondriasis (p < .01), scale 3, Hysteria (p < .05) and scale 7, Psychasthenia (p < .01) but not on scale 2, Depression. No other significant main effects or interactions were found. MMPI patterns for diagnostic categories are shown in Fig. 1. MMPI, gender and age. There were no significant differences related to sex and age groups (18-29;30-39;40-49;50-60 years old) on MMPI selected scales in the headache population. Daily Hassles and MMPI. The influence of microstress density on MMPI data was examined
by means of a 3 (groups: low, medium and high density daily hassles) x 4 MMPI scales (scale 1, Hypochondriasis; scale 2, Depression; scale 3, Hysteria: scale 7, Psychasthenia) analysis of variance (ANOVA). The ANOVA indicated significant main effects for the groups: F(11,320)= 23.76, p
G. De Benedittis and A. Lorenzetti
Reprint requests to: Giuseppe De Benedittis, M.D., Pain Research & Treatment Unit, Institute of Neurosurgery, University of Milan, 35, via F. Sforza, 20121 Milano, Italy Accepted for publication April 25, 1992 SYNOPSIS
This study investigated the relationship between minor life events (i.e. daily hassles) and personality patterns from selected scales of MMPI in the persistence of primary headache in 83 patients. Comparisons between headache subgroups indicated that tension-type headache patients are much more likely than those with migraine to have experienced high level of microstress (hassles density),with mixed headache in between. Tension-type headache patients reported higher MMPI scores on scales 1, Hypochondriasis (somatic concern), scale 3, Hysteria (denial) and scale 7, Psychasthenia (anxiety), but not on scale 2 (Depression), than migrainous patients. In addition, individuals with high level of microstress appeared to be more depressed and anxious than low-stress headache patients, scoring significantly higher on MMPI scales 2 (Depression) and 7 (Psychasthenia). As no significant differences due to sex, age, headache history and status, except for the headache density (i.e. severity x frequency) appeared, it is likely that high-stress levels are due, at least in part, to greater density of pain, rather than to discrete headache syndromes. Our findings support the notion that depressed mood and anxiety may account for a third intervening variable in the relationship between chronic headache and life stress. Key words: Headache; Stress; Life events; Daily hassles; MMPI. Abbreviations: HS Hassles Scale, VAS Visual Analogue Scale IPQ Italian Pain Questionnaire, MPQ McGill Pain Questionnaire, PPI Present Pain Intensity, PRI-T Pain Rating Index-Total, HI Headache Index, HD Headache Density (Headache 1992; 32:330-332) INTRODUCTION
Chronic primary headache is by far the most common chronic pain syndrome which, due to the complex multifactorial aetiology1, has been shown to be often associated with emotional stress.2-4 In fact, stressful life events have been implicated in the onset, exacerbation and maintenance of headache.5-9 In addition to the major life events approach, Lazarus and his group10-14 have recently focused attention upon the great adaptational significance of the relatively minor stresses, or daily "hassles", that characterize everyday life and may be a better approach to the prediction of health outcomes than the usual life events approach.12 The observed association between stressful life events and primary headache may be spurious, however, due to a "third variable", that might be correlated with both life events and headache.15 Personality traits are such a likely intervening variable. Despite the clinical relevance of the problem, the relatively few attempts to find psychological test patterns which are characteristics of headache patients have been controversial and generally disappointing.16-20 Headache patients, particularly tension-type and mixed headache sufferers, consistently show elevated scores on neurotic scales, but it is seldom clear whether these abnormalities precede the headache or are the consequence of it. Moreover, significant differences among headache diagnostic groups are rarely seen, when other variables such as age, sex, frequency, duration and severity of pain are controlled.18 In a previous study investigating the relationship between minor stressful life events (daily hassles) and the persistence of primary headache,9 using both normative group ratings and self-report ratings, we have shown that relatively minor life events, but not major life events, are significantly associated with the persistence of primary headache. Since probably no person leads a hassle-free life, the impact of hassles must depend not only on the chronically high frequency of hassles but also on its content and meaning in the person's life as well as on personality traits and coping skills.12 The aim of the present study was therefore to extend our previous investigation to evaluate the relationship of daily hassles with personality traits as "event mediators" in the persistence of primary headache. MATERIAL AND METHOD
Subjects. Eighty-three patients admitted consecutively to the Pain Research & Treatment Unit, Institute of Neurosurgery of the University of Milan, with a diagnosis of chronic primary headache participated in the study. Fifty-eight were females (69.9%) and twenty-five were males (30.1%). Their age ranged from 18 to 60 years (mean ± SD: 37.4 ± 11.7).
To be considered eligible for the study, headache patients were required to meet the following inclusion criteria: (a) ages 18-60 inclusive; (b) headache duration of at least two years (mean duration ± SD = 14.7 ± 10.6 years); (c) minimum frequency of four attacks per month (mean frequency ± SD = 16.3 ± 10.4). Headache subgroups, diagnosed according to the Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain of the Headache Classification Committee of the International Headache Society21, included: (a) chronic tension-type headache (n=35); (b) migraine (n=27); (c) mixed headache (n=16) and (d) cluster headache (n=5)(. An age, gender and socioeconomic status matched sample of fifty-one subjects was chosen for the control group. Thirty-three were healthy, pain-free subjects, while eighteen were neurosurgical patients, with negative headache history. Thirty-one subjects were females (60.8%), twenty were males (39.2%). The age ranged from 24 to 55 years (mean age ± SD = 32.6 ± 6.5). Procedures. All the patients were in the "waiting list" for specific treatment at the Pain Research & Treatment Unit of the University of Milan. In order to obtain reliable baseline data, during the study patients were not allowed the use of prophylactic drugs, but only the occasional use of symptomatic ones (i.e. in case of unbearable headache). Symptomatic drug abuse in migraine patients (e.g. ergotamine compounds) was not allowed, in order to avoid rebound-headache. A cohort study-design was adopted. Each participant received several measures assessing different dimensions of stressful life events (major life events, minor daily events) and of pain status. (1) Minor Life Events. In order to evaluate the role of daily hassles (i.e. repeated, "minor" ongoing stresses and strains of daily living) on the persistence of headache, a prospective study design was adopted. Headache patients and control group were given The Hassles Scale.12 The Hassles Scale (HS)12 is a questionnaire consisting of 117 items, hassles, which a person could have experienced in the previous month. In addition, respondents rated each hassle for how disturbing it was on a 3-point scale ranging from "not much" to "very much". The HS was administered once a month for 3 consecutive months as a part of a 3-month period longitudinal study. Two summary scores for each HS were generated for analysis: (a) frequency, a simple count of the number of items checked, which could range from 0 to 117; (b) density, which was the monthly mean severity (i.e. frequency x severity rating) reported by participants for all items checked. (2) Personality Traits. The Minnesota Multiphasic Personality Inventory (MMPI) was utilized to examine clinical correlates of behavior.22 This questionnaire contains 550 true and false items designed to give information regarding an individual's current personality profile. For the purpose of this study, scales examined in headache patients were scale 1, Hypochondriasis (symptom preoccupation), scale 2, Depression, scale 3, Hysteria (denial) and scale 7, Psychasthenia (anxiety). These scales were chosen because they have been shown to be important predictors of headache subgroups and to provide information regarding the presence of depression or "masked depression".17-19,23 Raw MMPI scores were converted to T scores using the Swenson et el.24 norms for 50,000 medical patients. All scores were of K-corrected values. (3) Pain Status. Baseline assessment of headache frequency, severity and quality was made by means of the following indices: (a) the headache history (years); (b) the Headache Index (HI), i.e. number of headache attacks per month, monitored by a daily pain diary; (c) the Headache Density, (HD), i.e. severity of attack times frequency. The severity of attack was rated on a 1-3 scale, with respect to pain intensity and disability (degree 1, mild, undisturbing attack; degree 2, moderate, disturbing attack; degree 3, severe, incapacitating attack); (d) the Visual Analogue Scale (VAS) and (e) the Italian Pain Questionnaire (IPQ),25 the national analogue of the McGill Pain Questionnaire (MPQ).26 The following indices were taken into consideration: (a) the 5-point Present Pain Intensity (PPI) scale, which measures the overall present pain intensity; (b) the Pain Rating Index - Total (PRI-T), which is a global measure of the multidimensional experience of pain. (4) Statistical analysis. The following procedures were used for the statistical analysis: (a). Frequency calculations including arithmetic mean, median, mode, standard deviation and standard error. (b). Differences between and within groups/subgroups of dependent variables were analyzed by the ANOVA (multiple comparisons). Significant effects were further analyzed using the Tukey's post hoc test. (c). Associations between independent and dependent variables were measured by correlation analysis (Pearson product-moment correlation ). RESULTS Minor Life Events. Daily hassles density and headache subgroups. As the correlations between the frequency and density of hassles were remarkably high (r= 0.76, p < 0,001), subsequent analyses were performed only for the density scores, which better reflect the perceived impact of hassles on individual daily life patterns. Low, medium and high scorers were determined by using median splits for the bottom, middle and top thirds of distribution. Low scorers reported an average of 58 hassle density scores, those with medium scores were affected by an average of 96, and those with high scores reported an average of 188 scores over the 3 month period study. Table 1 shows that tension-type headache patients (TTH) are much more likely than those with Migraine (MIG) to have experienced high level of stress (hassles density), with mixed headache patients (MIX) in between (X2 = 9.32, p < .025). Table 1 Daily Hasses Density Low Medium Cluster Headache 1 (4.5%) 2 (9.5%) Migraine 10 (45.5%) 14 (35%) Mixed Headache 5 (22.7%) 6 (15%) Tension-type h. 6 (27.3%) 18 (45%) N= 22 (100%) 40 (100%) Syndromes
High 2 (5%) 3 (14.3%) 5 (23.2%) 11 (52.4%) 21 (100%)
Daily hassles density, gender, age and pain-related variables. There were no significant sex-related differences in daily hassles magnitude. The influence of age, headache history and status (headache index and density, VAS, PPI, PRI-T) on the above mentioned measures was also examined by means of separate ANOVA. Statistically significant differences were found for the
headache density variable only, with high-density daily hassles patients reporting higher headache density than medium (p < .05) and low density subjects (p < .01). No statistically significant differences were found for the remaining variables. MMPI. MMPI. Headache patients vs controls. The influence of headache status on MMPI data was examined by means of a 2 (groups: CPH patients, headache-free controls) x 13 (MMPI scales: (3 validity, 10 clinical) analysis of variance (ANOVA). The ANOVA indicated significant main effects for the groups: F(25, 1754= 37.30, p < .001). The post-hoc analysis (Tukey's test) showed significant differences on scales 1, Hypochondriasis (p< .01), scale 2, Depression (p< .01) and scale 3, Hysteria (p < .01), with headache patients scoring significantly higher than controls. MMPI and diagnostic categories. The influence of diagnostic categories in the headache population on MMPI selected scales was examined by means of a 3 (groups: tension-type headache, TTH; mixed headache, MIX and migraine, MIG) x 4 MMPI scales (scale 1, Hypochondriasis; scale 2, Depression; scale 3, Hysteria: scale 7, Psychasthenia) split-plot ANOVA. Cluster headache category was not considered for statistical analysis because of the paucity of the sample (n=5). The post-hoc analysis (Tukey's test) showed that TTH patients scored significantly higher than MIG patients on scale 1, Hypochondriasis (p < .01), scale 3, Hysteria (p < .05) and scale 7, Psychasthenia (p < .01) but not on scale 2, Depression. No other significant main effects or interactions were found. MMPI patterns for diagnostic categories are shown in Fig. 1. MMPI, gender and age. There were no significant differences related to sex and age groups (18-29;30-39;40-49;50-60 years old) on MMPI selected scales in the headache population. Daily Hassles and MMPI. The influence of microstress density on MMPI data was examined
by means of a 3 (groups: low, medium and high density daily hassles) x 4 MMPI scales (scale 1, Hypochondriasis; scale 2, Depression; scale 3, Hysteria: scale 7, Psychasthenia) analysis of variance (ANOVA). The ANOVA indicated significant main effects for the groups: F(11,320)= 23.76, p
