PERSONALITY, DEPRESSION AND HEADACHE TYPE Roger A. Davis, M.D. Richard D. Wetzel, Ph.D. Tetsuo Kashiwagi, M.D. James N. McClure, Jr., M.D. Supported in part by U.S.P.H.S. Grants MH05804, MH13002, MH00552. Accepted for publication: 7/9/76 SYNOPSIS Seventy-four subjects with a chief complaint of headache of functional origin were tested using the California Psychological Inventory (CPI). No associations were found between individual headache types and personality dimension factors on the CPI. The differences found related to the effect of depression on psychologic test performance. Future studies of personality and headache types need to control for the effect of depression on psychologic testing. (Headache 16:246-251) THE ASSOCIATION between headache and personality has been postulated in the literature. Friedman1 wrote "the personality structure of the migranoid predisposes him to chronicity. Specifically, most migraine patients were not permitted to express emotions of anger and rage as children . . ." "Their personality structure is characterized by perfectionism, neatness, ambition, rigidity, and efficiency." He also suggested an association of depressive illness and migrainous attacks. However, Kashiwagi, McClure, and Wetzel2 did not find a significant association between depression and migraine. Psychologic testing to evaluate possible associations have consistently shown that headache patients are distinguishable from other patients. Harrison3 concluded that headache patients tended to think poorly of themselves, are more neurotic and more forgetful than controls. In a controlled study4 using the Maudsley test, 32 migraine patients were more neurotic than 34 patient and 34 non-patient controls. Henryk-Gutt and Rees5 also using the Maudsley, found that 40 classic migraine patients and 50 common migraineurs were more neurotic than 50 non-headache patients. Using an original questionnaire on all types of headache patients, they were found more depressed, had more psychosomatic pain, anxiety, and amnesia than non-headache psychiatric outpatients.6 Ragado, et al.7 also found headache patients to be more forgetful than controls and suggested the memory difficulty might be due to poor concentration because of neurotic anxiety. While previous studies have been able to separate headache patients as a whole from non-headache patients, efforts to distinguish individual headache types have not been successful. Waters and O'Connor8 used the Cornell Medical Index and found no difference between migraine and other type headache patients in neuroticism. In the present study of California Psychological Inventory of Gough9 a measurement of normal personality was used to distinguish different headache types. METHODS All seventy-four subjects who completed the California Psychological Inventory (CPI) were included in this study. They presented with a chief complaint of headache and were thought by neurologists to have functional headaches. A structured interview was given to all subjects. The interview included questions on medical, family, school, job, social,

psychiatric and headache histories. Psychiatric diagnoses were made using the psychiatric research criteria of Feighner, et al.10 and Woodruff, et al.11 The Ad Hoc Committee of Classification of Headaches12 criteria was used for diagnosis. a. Psychiatric diagnoses were divided into three groups: 1. All patients with depression whether primary or secondary. 2. All patients with other psychiatric illnesses. 3. Patients with no psychiatric illness. b. Headaches were typed as follows: 1. Patients with vascular headaches. 2. Patients with muscle contraction headache. 3. Patients reporting combination headache-with vascular and muscle contraction elements. This group also includes less well defined "other headache" types. The 74 patients represented a group with a higher percentage of high school graduates than in Kashiwagi's study.2 RESULTS Twenty-nine patients (39%) had vascular headaches twenty-three (31%) had muscle contraction headaches, twenty-two (30%) had combination or other headaches. Forty (54% - five males, thirty-five females) of the 74 had either primary or secondary depression, twelve (16%-three males, nine females) had other non-affective psychiatric disorders. Twenty-two (30%-five males, seventeen females) had no psychiatric illness. Two-way analyses of variance of the 18 CPI scale scores were computed. Significant main effects due to psychiatric diagnosis was obtained on 7 of the 18 scales. No significant main effect due to headache type or significant interaction involving headache type was found on any scale. Table 1 represents the means and standard deviations of CPI scale scores by psychiatric diagnosis only. Table 2 shows the results of analysis of variance on each of the CPI scales. The 7 significant CPI scales were Wb (sense of well-being), Sc (self-control), To (tolerance), Ac (achievement via conformance), Ie (intellectual efficiency), Py (psychological-mindedness), and Fe (femininity). The Duncan multiple range test was used to determine which group differences led to the significant main effect. Table 3 shows the results of the analysis for each of the seven scales with interpretive remarks about high or low scores in each scale. Using the Duncan test, the sense of well-being, self-control, achievement via conformance, and intellectual efficiency showed depressive patients statistically significantly lower (p = 0.05) than the no psychiatric illness patients. The psychological mindedness scale showed the depressive group to be significantly lower statistically (p = 0.05) than the other psychiatric illness group. On two scales (tolerance and femininity) the depressed patients were found statistically different (p = 0.10) from both no psychiatric illness and other psychiatric illness groups. Depressed women had significantly (p