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University This is to certify that the thesis entitled THE ROLE OF PERSONALITY IN MIGRAINE CAUSATION presented by David Morris Schnarch has been accepted towards fulfillment of the requirements for Pk D ____degreein______ [f76mps‘lcuuacr flaw %;% «m Major rrop ofessor Date M [6176 U m MSU LIBRARIES RETURNING MATERIALS: Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. .. l - r" .. _. ./ , a V ‘. , J; ,4 m:- t. V 7 EA WAR *- A w It {7" :5... g 2 2000 ABSTRACT THE ROLE OF PERSONALITY IN MIGRAINE CAUSATION By David Morris Schnarch Since the early l930's and the publication of Freud's initial theories of the unconscious, conversion symptoms, and psychosomatics; two predominant schools of thought have developed in regard to the causation of migraine headache. The constitutional model suggests that migraine results from autonomic nervous system activity which exceeds the vascular hypersensitivity of genetically predisposed people. The psychodynamic model suggests that the unconscious pro- duces migraine as a way of coping with internal or interpersonal crisis. More specifically, psychoanalytically-oriented authors sug- gest that migraine results from chronic repression of anger. Over the years, a considerable number of reports of particu- lar personality traits of migrainous psychotherapy patients accumu- lated, which loosely tended to support a 'migrainous personality' profile. However, a recent review of the literature revealed that existing research was equivocal in regard to the two predominant David Morris Schnarch theories of causation. Serious methodological problems and outright conflicts in reported results made it impossible to evaluate the utility of either theory in accounting for available information on the role of personality in migraine causation (Schnarch, l974). The present study was undertaken to systematically evaluate reports of particular personality traits in migrainous people, and in particular, the psychoanalytic model of migraine causation. Con- siderable attention was devoted to avoiding the methodological prob- lems of previous research. The "Clinical Treatment Fallacy," wherein results based on migrainous psychotherapy patients were often gener- alizied into causal inferences for all migraine sufferers, was given particular consideration. The present study was designed to assess personality characteristics of non-patient migraine sufferers. Exten- sive control groups were included in the experimental design. Based on psychodynamic models of migraine causation and pre- vious reports of personality dynamics in the literature, several ob- jectives were developed for the present study. The first objective was to verify previous reports of personality traits of migrainous people. The following traits were examined: fears of expressing anger trait anxiety negative afterthoughts self-concept awareness of anger parental attachment David Morris Schnarch expression of anger sexual experience resentment of other people dating experience suspicion of other people self-revelation rigidity of lifestyfle work endurance acceptance of premarital sexuality parental disciplinary styles Multiple sub—scales for several of these traits were used to permit close examination of personality characteristics. A total of 30 per- 'sonality scales were used in the present study. The second objective was to examine the psychoanalytic model of migraine causation. Three hypotheses were developed and explored in the present study: I. Migrainous people repress more anger than non-migrainous people. Specifically, it was hypothesized that migrainous §§_would express less anger and report lower awareness of being angered by frustrating events. Moreover, migrainous §§_would report more traits indicative of underlying re- pression. II. Migrainous §§_would report more personality traits that would predispose them to anger than non-migrainous §§, David Morris Schnarch III. Migrainous §_§_ would report more traits that could weaken the adequacy of repressive defenses (i.e.: pre-genital fixations) than non-migrainous _S_s_. A total of 5,253 undergraduate students living on campus at Michigan State University during Spring term, 1975, were contacted by mail and asked to complete a brief questionnaire. This questionnaire was similar to the one developed by Waters (1969) and allowed S_s to be diagnosed for the type and severity of headaches they experienced. 0f the 36l6 §_s_ (68.8%) returning the diagnostic questionnaire, 3200 S_s; were recontacted and asked to complete a lengthy personality ques- tionnaire. Responses were obtained from 2306 _Ss (72.0%). Control group data on the diagnostic questionnaire were obtained from an additional 293 New York University students, 1293 adults at, a local s"'I0pping center, 26 patients at a Conmunity Mental Health Center, and 55 student patients at the Michigan State University Counseling Center. Preliminary findings regarding instrument characteristics and ep ‘idemiological incidence of migraine in selected and non-selected populations are presented. Instruments were found to have good psy- chometric characteristics. Results indicating differences in migraine 1 "C 1 dence, severity of headache, and referral for headache treatment David Morris Schnarch between patient and non-patient populations tended to confirm concerns 01’ sample selection bias in previous research. Overall, results fail to support previous reports of specific personality traits among migrainous people. No significant differ- e"Ices between migrainous and non-migrainous people were found on any 01'“ the personality traits listed above, save for two. Migrainous people were found to be significantly more suspicious and more fear- ‘Fu 1 of expressing anger than non-migrainous people. However, these d ‘i fferences were actually quite small in an absolute sense. Group "lean profiles were observed to be virtually identical on all remain- ‘i ng personality traits. Additional findings regarding personality (1 'i fferences between severe and non-severe headache sufferers and be- tween male and famine headache sufferers are presented. In view of the lack of consistent personality differences be- tween migrainous and non-migrainous people. the present study offers 1 i ttle support for psychodynamic models of migraine causation. More- over, it offers no support for the suggestion that repression of a n Qer causes migraine. The disparity of the present results with previous reports is reconciled by consideration of the pervasive methodological flaws in earlier investigations. Some support for the constitutional model is evident in personality traits found to David Morris Schnarch di stinguish migraine sufferers who have high and low frequency of attacks. Implications of the present results for migraine treatment are considered. THE ROLE OF PERSONALITY IN MIGRAINE CAUSATION By David Morris Schnarch A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1976 © Copyright by DAV I o MORRIS scnmacu I 9 76 DEDICATION To my parents, Stanley and Rose Schnarch. As we each have found more of ourselves in the last few years, we seem to have found more of each other. ACKNOWLEDGEMENTS In the process of completing this dissertation, I have become ‘3 ndebted to a vast population of kind people. Foremost, I wish to thank the members of my dissertation comittee. Dr. Jack Hunter has been involved in this project since its outgrowth from my Master‘s Thesis, of which Jack was Chairman. As Co-Chairman of this disserta- ti on, Jack has been involved in every phase and his foresight and understanding of research methodology and evaluation has considerably benefited this project. Jack offered particularly valuable input “i nto the development of the measurement instruments, and personally developed several of- the computer programs used in analysis of the data. Special thanks also go to Dr. Don Grumon, who also served as Co-Chairman. Don helped maintain the clinician's viewpoint in the midst of stacks of questionnaire forms and computer output. Don suQQested the title for the phenomenon of the 'Clinical Treatment Fa‘ 1 acy' and much of what appears in this regard is a direct out- g"‘OWth of our conversations. His conments have shaped the final foWation of this document, including the differentiation of the ii obj ectives, and the development of Table l. I could not ask for better Co-Chairmen for my comittee. Both men provided stimulation and support when my ideas were stale, and my pessimism was rampant. I also wish to thank Dr. Al Rabin and Dr. Bob Calsyn, who Served as comittee members for this diss‘ertit'Ton. Al's coments on Psychoanalytic theory was invaluable in clarifying the limitations 01'“ operationalizing the concept of repression, understanding the im- p‘l ications of the results for this complex school of thought. A study of this scope and depth is demanding of many re- sources: money. access to subject populations, data scoring and analysis, and manpower. The financial support for this study was provided by a Eederal Bio-Medical Research Grant, and funds from the M - S.U. Department of Psychology. I am indebted to Dr. Charles Manley, Dean of the College of Social Science for his aid in securing the re- search grant, and to Dr. Jack Hakeley and Mr. Roger Halley for their he? p in obtaining departmental support. Several agencies cooperated in the collection of data for th is project. Thanks go to: The Administration of Michigan State University Receptionists at the M.S;U. Residence Halls Dr. Ralph Kron and the M.S.U. Counseling Center Sara Weber and the Department of Psychology at New York University iii Dr. Michael Barnat and the Livingston County Comunity Mental Health Center, Michigan The Management of Meridian Mall Shopping Center, Okemos, Michigan ' The scoring of responses was handled by the M.S.U. Evaluation Service. Special thanks go to Bill Brown. of the M.S.U. Computer Lab, who served as computer consultant in the analysis of the data. Data analysis was performed at this facility. Ted Urban's heavy invest-s merit in the data collection and‘data analysis has also been greatly a p preci ated . It takes a small army to stuff over l7,000 envelopes and sample almost 8,000 subjects. The following people are part of the honor roll of good souls who helped do it. They are the 'hands and «Feet' of the study: Mrs. Eddie Golden Becky Hollingsworth Gina Schack Daniel Pritchard Pam and Keith Bakeman Maynard and Caroline Berry Chad Bakeman Joel Engel Debbie Phelps Bob Fairweather Jim Nuttall Mathew Biafora Joyce Messenger Marry Ellen Duffy John Alexander Laurie Breisch Denise Lucy ‘Susan Ruppman iv Pam Duff - Regina Vavere Victor and Rachel Asbury Heidi Stein Special thanks go to Pam Bakeman who suffered through two separate proof-readings of this document. My gratitude to my wife, Nelia, goes far beyond the scope of this dissertation. It covers the last seven years of graduate school, and our relationship of 12 years in which we have laughed, wept, and become more mature. She has both my love and respect as a separate person in her own right. TABLE OF CONTENTS Page LIST OF TABLES ......................... xi LIST OF FIGURES ........................ xiii L IST OF APPENDICES ....................... xx CHAPTER ONE: INTRODUCTION ................... 1 Problems of Methodology in Past Research .......... 3 Overview of the Present Study ............... 10 Previously Reported Personality Traits of Migraine Patients 14 Primary Traits: Repression of Anger ........ i . . l4 Secondary Traits .................... 24 Control Groups ....................... 37 C:""'AF‘TER THO: OBJECTIVES OF THE PRESENT STUDY ......... 4O (Hajective One: Examination of Personality Traits of Migrainous People .................... 40 (Diajective Two: Examination of Psychoanalytic Formulations of Migraine ........... . ..... 42 Hypothesis IA: Expression and Awareness of Anger. . . . 44 Hypothesis IB: Indirect Expression of Repressed Anger . 45 vi TABLE OF CONTENTS (cont'd.) Page Hypothesis II: Predisposition to Anger ......... 46 Hypothesis III: Energy Reserves for RepresSion ..... 47 (IIII\PTER THREE: METHODOLOGY .................. 49 Instrument Development: The Pilot Study .......... 49 Identification of Target Populations ............ 50 Administration of the Diagnostic Questionnaire ....... 53 Administration of the Personality Questionnaire ...... 55 (:filkPTER FOUR: INSTRUMENTATION CHARACTERISTICS ......... 58 Chapter Summary ...................... 58 Reliability ....................... 58 Content Validity .................... 58 Construct Validity ................... 63 Scale Reliability ..................... 65 Scale Content Validity ................... 67 Scale Construct Validity .................. 67 Intercorrelation of Personality Scales ......... 67 Relation of Personality and Background Scales ...... 8l vii TABLE OF CONTENTS (cont'd.) (ZIJIEPTER FIVE: INCIDENCE OF MIGRAINE HEADACHE IN SELECTED AND NON-SELECTED POPULATIONS ................ Chapter Summary ...................... Populations Sampled ................... Migraine Incidence ................... Comparability of Populations .............. Headache Composition of the M.S.U. Sample ........ \Criteria for Headache Diagnosis ........ ‘ ...... Migraine Incidence in Patient and Non-Patient Populations . Symptomatology ..................... Migraine Incidence . .................. Headache Treatment ................... Incidence and Characteristics of Various Types of Headache in a Randomly Selected Population ............ Background Characteristics of the M.S.U. Sample ..... Intercorrelation of the Background Variables ...... Specific Characteristics of Headache Groups in the M.S.U. Sample ............... t . . Headache severity .................. Medical treatment of headache ............ Headache frequency .................. Sex composition . . ................. Headache causation .................. General adjustment .................. viii Page 85 85 85 85 87 87 89 9O 91 94 97 99 99 102 105 109 110 110 111 114 115 F TABLE OF CONTENTS (cont'd.) Page (:F1l\PTER SIX: PERSONALITY DIFFERENCES BETWEEN MIGRAINOUS AND NON-MIGRAINOUS PEOPLE (THE TESTING OF THE EXPERIMENTAL OBJECTIVES) ........................ l20 Chapter Summary ...................... 120 Differences Between Severe Migraine and Severe Tension Headache §§_ ..................... lZl Implications for the Psychoanalytic Model ........ 122 Additional Findings ................... 123 Data Used for Hypothesis Testing .............. l24 Differences Between Severe Migraine and Severe Tension Headache §§_(Objective One) ............... l26 Background Differences ................. l26 Personality Differences ................. l29 Examination of the Psychoanalytic Model of Migraine Causation (Objective Two) ................ l3l Hypothesis One ..................... l3l Hypothesis Two ..................... l38 Hypothesis Three .................... l39 Summary Of Hypothesis Testing .............. l43 Flesults Relevant to the Constitutional Model ........ 143 Summary of Additional Findings ............... l49 Severity of Headache .................. l49 Sex Differences ..................... lSl ix TABLE OF CONTENTS (cont'd. ) (:F1l\PTER SEVEN: DISCUSSION ................... Final Comments on the Data .......... ....... Instrument Validity and Reliability ........... Consideration of Social Desirability Effects ...... Migraine Incidence ................... Use of College Students as Ss .............. Consideration of Psychodynamic Causation of Migraine. . . . Impact of Methodological Flaws in Previous Research. . . Consideration of Differences in Traits Assessed ..... Predisposition to Confirm Previous Reports ....... Consideration of Recent Studies ............. Explanation of the Two Personality Differences Found in the Present Study ................. Consideration of the Psychoanalytic Model of Migraine Causation ........................ Consideration of the Constitutional Model ......... Relation of Personality and Headache Severity ....... 'The Clinical Treatment Fallacy ............... Implications for Treatment ................. B I BL I OGRAPHY .......................... A; ppENDICES ........................... X Page 153 153 153 155 156 157 159 160 162 163 164 167 169 174 177 179 182 185 191 ‘. LIST OF TABLES Table Page 1 . PREVIOUSLY REPORTED PERSONALITY CHARACTERISTICS OF MIGRAINOUS PEOPLE ................... 13 2:. DOMAIN OF QUESTIONNAIRE SCALES .............. 59 :3.. PSYCHOMETRIC CHARACTERISTICS OF THE PERSONALITY SCALES. . 62 41. INTER-CORRELATION OF THE SCALES ............. 68 £1!\. INTER-RELATION OF STYLES OF EXPRESSING ANGER ....... 72 £IE3. INTER-RELATION OF STYLES OF ANGER EXPRESSION AND PERSONALITY VARIABLES ................. 74 zT(:. INTER-RELATION OF PROVOCATION SUBSCALES ...... . . . 77 ¢1[3.. INTER-RELATION OF PROVOCATION SCALES AND PERSONALITY VARIABLES ................. 79 4E. INTER-RELATION 0F ANGER EXPRESSION STYLES AND PROVOCATION SCALES .................. 80 455 - INTER-CORRELATIONS BETVEEN PERSONALITY SCALES AND BACKGROUND VARIABLES ................. 82 453.. MIGRAINE INCIDENCE IN SEVERAL SAMPLED POPULATIONS . . . . 92 7"- BACKGROUND CHARACTERISTICS OF THE SAMPLE ......... lOO ‘ CORRELATIONS BETWEEN BACKGROUND VARIABLES ........ 103 xi LIST OF TABLES (cont'd.) Tab'l e Page satx. HEADACHE GROUP CHARACTERISTICS (PART I) ......... 106 SJEB. HEADACHE GROUP CHARACTERISTICS (PART 11) . .1 ...... 112 59:3. HEADACHE GROUP CHARACTERISTICS (PART III) ...... , . 117 59:). HEADACHE GROUP CHARACTERISTICS (PART IV) ........ 119 1 o . DIFFERENCES BETVEEN SEVERE MIGRAINE AND SEVERE TENSION HEADACHE S5, ....... . ...... 127 1 1 . RESULTS OF PARTIALLING REPORT OF 'ANGER GIVES HEADACHE' FROM 'FEARS OF EXPRESSING ANGER' ........... 134 '1 2:. SEXUAL EXPERIMENTATION AND ORGASMIC COMPETENCY IN SEVERE MIGRAINE AND SEVERE TENSION HEADACHE S5, . . . 142 ‘1 :3. PERSONALITY VARIABLES SIGNIFICANTLY CORRELATED HITH HIGH FREQUENCY OF ATTACKS IN MIGRAINE §§. ....... 147 Appendix ‘1 - SELECTED SCALES FOR MAIN STUDY ............. 201 22.- INTERCORRELATIONS OF SCALES USED IN THE PILOT STUDY. . . 205 133-. CORRELATIONS OF HEADACHE SEVERITY HITH PERSONALITY VARIABLES ................ 250 ‘4'-- CORRELATIONS OF GENDER HITH PERSONALITY TRAITS. . . . . . 264 xii LIST OF FIGURES F'i gure Page 1 . Differences between severe migraine and severe tension headache _Si in fears of expressing agger ........ 137 2. Differences between severe migraine and severe tension headache §§.in suspicion of others ........... 137 3. Differences between severe migraine and severe tension headache _S_s_ in parenta] attachment ........... 140 4. Differences between severe migraine and severe tension headache §§_ in dating experience ............ 141 5. Differences between severe migraine and severe tension headache §s_ in getting headaches from anger ...... 144 6 . Differences between severe migraine and severe tensiOn headache gig in particular foods causing headaches . . . 144 7 . Differences between severe migraine and severe tension headache §_s_ in dating causing headaches ........ 145 F\‘315’el'1dix E3- Differences between severe and non-severe headache §§_ in anger provoked by items assessed in the Provocation Scale . ......... . ........ 254 9 ~ Differences between severe and non-severe headache _S_s_ in trait anxiety. . . ................. 254 1 O - Differences between severe and non-severe headache _S_s_ in verbal expression of anger ............. 255 xiii L. I 51' OF FIGURES (cont'd.) F=’-i ggtJre 1 1. 1:2. 113. 14. 15. 16. 17. 18. 19. 20. 2!]. Differences between severe and non-severe headache §§_ in physical expression of anger ..... ' ...... Differences between severe and non-severe headache §§_ in negative afterthoughts .............. Differences between severe and non-severe headache §§_ in parental withdrawal of love as a disciplinary technique .................... ,. . Differences between severe and non-severe in parental attachment ................ Differences between severe and non-severe in sexual experience ................. Differences between severe and non-severe in suspicion of others. ; .............. Differences between severe and non-severe in feelings of resentment .............. Differences between severe and non-severe in rigidity of lifestyle ............... Differences between severe and non-severe in anger causing_headaches .............. Differences between severe and non-severe in dating causing_headaches ............. Differences between severe and non-severe in particular foods causing headaches ........ headache headache headache headache headache headache headache headache 55 SS * SS 55 ss 55 Page 255 256 256 257 257 258 258 259 259 260 260 LIST OF APPENDICES Appendix Page A. PERSONALITY QUESTIONNAIRE AND BACKGROUND INFORMATION. . 191 DIAGNOSTIC QUESTIONNAIRE ................ 206 COVER LETTERS FOR DIAGNOSTIC AND PERSONALITY QUESTIONNAIRE .................... 207 0. ITEM LIST FOR SCALES USED IN THE PERSONALITY QUESTIONNAIRE .................... 209 E. PARTIAL PRESENTATION OF DATA FROM BIHLDORF, KING, AND PARNES (197l) .................. 217 F. CODE BOOK OF PERSONALITY AND BACKGROUND SCALES ..... 2l8 6. ADDITIONAL DATA FROM THE PRESENT STUDY ......... 220 H. QUESTIONNAIRE MATERIALS USED IN SAMPLING 0F NEH YORK UNIVERSITY STUDENTS, MERIDIAN MALL éa. COMMUNITY MENTAL HEALTH CENTER S_s, AND M.S.U. COUNSELING CENTER _S_s_ ...................... 24s I . ADDITIONAL RESULTS ................... 247 CHAPTER ONE INTRODUCTION Migraine is usually defined as an episodic disturbance of cerebral functioning associated with incapacitating unilateral head- ache. Although headpain is the most prominent feature, diagnosis is based on the occurrence of several of the following symptoms: a sense of 'warning' of impending attacks (prodromes), such as nausea and vomiting, or extreme visual sensitivity to light inmediately pre- ceding attacks; headache is recurrent, throbbing, and usually uni- 1 ateral at onset; vertigo, tremors, sweating, dryness of the mouth, Dal‘lor of the skin, and chills during the attack; relatively perfect health between attacks (Schnarch, 1974). Although the physiological events which comprise the migraine attack have been clearly defined (Dubois-Reymond, 1860; Lennox and Von Storch, 1935; O'Sullivan, 1936; Graham and Wolff, 1938; Kimball, Fr“ledman and Vallejo, 1960; Anthony, Hinterberger and Lance, 1967; Larice, Anthony and Gonski, 1967; Lance, Anthony and Hinterberger, 1967; Lance, 1969; Wolff, 1972; etc.), the psychological aspects of "“i graine causation remain largely a mystery. A review of the research literature, which attempted to crit- ‘i cally evaluate the role of diverse factors in migraine etiology was recently completed (Schnarch, 1974). This review covered such areas as incidence and duration of attack, age of onset, sex differences, E. -E.G. abnormalities, and epilepsy. Reports of stress reactions, con- d1’ tioning, and personality and case history studies were also consid- ered in depth. Overall, the research literature on migraine was notable in 1 ts inability to critically evaluate the predominant conceptual models of migraine causation: the psychoanalytic model and the con- Stitutional model. In areas where reports were highly consistent, Such as duration and frequency of attack, available data offered 1 ‘ittle discrimination between theoretical models. Both theories Were consistent with the data. Perhaps the most important finding of this review was in re- gard to the personality and case history studies. Inconclusive re- ports and outright conflicts between reported results made it diffi- CUTt to evaluate the role of personality in migraine causation. Molr‘eover, the extent to which these studies were subject to serious methodological flaws made this task veritably impossible. This find- 1."9 was of considerable import, .inasmuch as these were the studies Wh‘ich spawned the psychoanalytic model of migraine causation. This review produced the Conclusion that basic research must be undertaken to establish the actual personality characteristics of migraine suf- ferers (Schnarch, 1974). Until these basic parameters are established by methodologically sound research, there is little value in further attempts to establish a causal link between personality and migraine causation. Problems of Methodology in Past Research Because the results and methodological problems of the exist- ing personality studies of migrainous individuals have been reported elsewhere by the present author (Schnarch, 1974), they will not be repeated here. However, inasmuch as the methodological flaws are of ”interest at present, the more comon problems will be summarized here. One all-too-common problem of previous research was the failure to include multiple interviewers in case history studies. This would have reduced the potential for observer biases affecting the outcome of the studies. Since the authors did not distinguish between their observations and their theoretical conclusions, it is pr‘Obable that their conceptual biases determined which portion of the case history would be considered "significant“ and which portion would be ignored. Moreover, since the interviewer was not double- b1 ind, his behavior may have evoked, rather than “uncovered,“ certain personality traits in migraine patients. Similarly, even if the in- terviewer‘s behavior could have been proven to be uncorrelated with the client's migraine status, his interpretation of the behavior and free-associations of migrainous people may have been biased by prior hypotheses about migraine, per se. Most of the support for the psychoanalytic formulation was derived from the trait interpretations and trait-based inferences of the investigator, and not from primary observation itself. Unre- corded psychotherapy and interview sessions do not permit the reader to examine the data for himself. Moreover, many investigators used migraine as a vehicle to validate some of their firm beliefs about the nature of psychopathology (ex: From—Reichmann, 1937; Furmanski, 1952). From the amorphous data of long case histories and free- aSsociations in therapy sessions, these investigators could always find some pieces to support their contention, but this might have been equally true for any other hypothesis they started out with. A second pervasive methodological flaw was the failure to include control groups in the research design. This shortcoming was c:9II‘Inon to previous research (Touraine and Draper, 1934; Weber, 1932; Wolff, 1937; Fromm-Reichmann, 1937; Furmanski, 1952; Knopf, 1935; Sperling, 1952). Often, the patient's behavior was interpreted to i ndicate personality traits supportive of the psychoanalytic model. While the investigator often provided a rationalization for finding these traits in migrainous people, no attempt was ever made to show that these traits were found any more frequently in migrainous indi- viduals than in nonmigrainous people. Thus, no evidence was offered ' that these traits were causal of migraine. The lack of control group data presented problems in other aspects. Judgments of restricted sexual functioning, basic to the psychoanalytic suggestion of infantile fixations, seemed to be made with a theoretical model of mental health in mind, rather than a group of randomly selected individuals. Thus, reports of restricted Sexuality were totally dependent upon the individual investigator's conceptualization of “complete psychosexual development.“ Although there was considerable variance between reports (which made it diffi- CUlt to evaluate theoretical models of causation), the areas of aQr‘eement that did exist may be solely attributable to mutual agree- mtint on psychoanalytic principles. It should be noted that even the most basic research on mi- graine is riddled with methodological flaws. The problem of _Si is a rnajor case in point. Invariably, previous research always drew §_5_ from the group of migraine sufferers who sought pharmacotherapy or psychotherapy. However, in sampling an entire community, Waters (1970) found that almost 50 per cent of the people who qualified for the clinical diagnosis of migraine had never sought medical attention for their headaches. Sperling (1952) pointed out that headache is sometimes a necessary part of a working solution to an emotional problem. More- over, poor people often do not seek treatment or are misdiagnosed at hospital clinics. These reports suggest that significant selection biases are so large that research findings based on migraine patients may not be applicable to migraine sufferers in general. Thus, previous research must be considered in light of the “Clinical Treatment Fallacy." The clinical treatment fallacy occurs When psychotherapists attempt to make causal inferences into the eti- ology of a type of psychopathology in all people who have the dis- 0r‘der by extrapolating from their treatment experiences with their particular clients. The concern for the clinical treatment fallacy is ramified by the recent finding that migraine sufferers undergoing treatment in a C1 inic were more neurotic than migraine sufferers indentified at ran- dom in the general population (Henryk-Gutt and Rees, 1973). More- oVer, there are other indications that self-selection factors exist, tacath for people who do not seek treatment (and are systematically ex- <:7luded from migraine research) and for people who remain in treatment ( and make up the pool of research S_s_): It is a constant source Of amazement to me why so many patients to whom we can not supply specific and prompt relief keep coming back to the same doctor. Why, after 8, 10, 12, 15, 20, a hundred visits; and they still have their headaches, do they keep coming back? They keep coming back because you help them to handle their symptom and not because you cure them; and this same group of patients might be very worse off if you ever did cure them. (p. 11, Garner, Shulman, MacNeal and Diamond, 1967) Some recent research in the area of essential hypertension highlights the problem of the clinical treatment fallacy in formula- . ti ons of other psychosomatic disorders. Kidson (1973) conducted a Study in which he compared personality traits of 40 hypertension Patients with those of 110 hypertensive non-patients. The latter group of S_s were randomly selected from 1000 industrial and scien- trific employees, who were diagnosed by medical examination. Hyper- 1:ension patients were found to be more neurotic, more insecure, and more tense than non-patients when responses to the Cattel l6PF Ques- 11‘! onnaire were compared. Previously, Robinson (1964) had suggested that diagnostic procedures led to high neurotic hypertensives having a greater like— "Tl1ood of being discovered than less neurotic individuals with equally high blood pressure. This was subsequently confirmed by Cochrane (1969). Cochrane (1973) conducted a similar study to Kidson's (1973). Cochrane's study tested Alexander's formulation (1939) that hyperten- sion resulted from chronic inhibition of anger. According to Alexan- der's theory, essential hypertensive people repress and inwardly direct their hostility more than normotensive people do, thus causing their hypertension. Moreover, Cochrane examined Sainsbury's report (1960) that people suffering from psychosomatic disorders were gener- ally more neurotic than people without psychosomatic disorders. Cochrane (1973) found no evidence that essential hypertension was re- lated to emotional instability or traits of hostility, when non- ' patient hypertensive and normotensive §§_were compared. Extensive control group and matching procedures were used in this study, and results were quite clearly defined. The studies by Kidson (1973) and Cochrane (1973) are of in- terest to the present discussion insofar as the clinical treatment fallacy seems involved in the etiological models of psychosomatic disorders aside from migraine. Moreover, it is interesting to note that while essential hypertension and migraine have been suggested to result from similar dynamics (i.e. repression of anger), these studies failed to confirm this in the former disorder. Clearly, there is reason to suspect that trait reports of migrainous psychotherapy patients cannot be generalized into causal inferences for all migraine sufferers. Yet, to date, the predomin- ant theories of the role of personality in migraine causation have evolved from research based on the clinical treatment fallacy. The problems Of§_s_ selection bias permeate even such basic research areas as rate of incidence. Moreover, data on other basic parameters, such as age Of onset, is also questionable. Consider that onset does not necessarily refer to the first attack. Rather, data on 'onset‘ probably reflects the beginning of chronic and/or severe headaches that demand medical attention. Individuals with mild or infrequent migraine attacks may never seek treatment. Clearly, not all migraine sufferers are migraine patients. Yet, when the role of personality in migraine etiology is at ques- tion, it is just as important to include the traits of these indi- viduals in our sample with those of the more chronic or severe migraine sufferers. With the basic parameters in question, it is not surprising that complex entitites, such as personality traits, are not clearly established. 10 Overview of the Present Study There has long been a controversy raging over the cause of migraine headaches. Two theories have generally developed: a consti- tutional model and a psychodynamic model. The constitutional model is based on the assumption that migraine susceptibility arises from genetically transmitted hypersen- sitivity of the cranial arteries to fluctuations of serotonin level in the blood stream. Specific attacks are assumed to occur when any strong emotional reaction or physiological change ekaes sufficient variations in serotonin level. The unique personality structure of each individual is suggested to determine the situations that are capable of triggering migraine attacks. Particular feelings or per- sonality traits of migrainous people are not predicted by the con- stitutional model. However, stronger affects such as rage or massive anxiety are considered more likely to generate the sympathetic ner- vous system activity that creates relatively large deviations in serotonin level. The predominant psychodynamic theory is that originally put forward by Fromm-Reichmann (1937). She started with the assumption that the unconscious has the power to inflict physiological damage_ as a self-punishment for hostile impulses toward sacred loved ones. 11 She then derived from psychoanalysis a specific etiology for such massive repression which seemed to fit her patients. Although subse- quent writers have quarreled with many of her assumptions, the cen- tral importance of repressed anger has been the dominant theme of all the psychodynamic theories. Each psychodynamic theory of migraine has two parts. All psychodynamic theories assume that migraine headaches are produced by the unconscious as a way of coping with a personality crisis. The various theories differ from one another in their explanation of what personality traits contribute to the creation of the crisis. The constitutional and the psychodynamic theories Of migraine are not mutually exclusive. Many of the constitutional theorists have argued that the specific trigger for an attack of migraine might be an extreme emotional reaction. Thus, among those who are unfor— tunate enough to have inherited migraine potentiality, there might be a correlation between personality stress and frequency of attacks. The present study provides a preliminary test of the psycho- dynamic models by presenting data concerning the personality differ- ences between migrainous and non-migrainous people. To date, it is the first adequately controlled and methodologically sound examina- tion of its kind. In the remainder of this introductory section the results of previous studies examining the personality traits of 12 migrainous people will be reported. It should be mentioned that some of the authors to be cited conceptualized their own results within the constitutional model. Two examples Of such authors are Touraine and Draper (1934) and Wolff (1937). However, in these and other cases, their trait profile reports were almost identical to reports from psychoanalytically-oriented writers. Moreover, their results are both relevant'and consonant with the psychoanalytic model. Constitutionally-oriented authors will be footnoted when their re- sults are discussed. However, the reader is again referred elsewhere (Schnarch, 1974) for a complete analysis and discussion of the intri- cacies of theory and research that will be outlined here. A summary of the trait reports of previous investigators is presented in Table 1. Table 1 also contains a brief indication of the methodological problems specific to each study. In the following pages, these trait reports will be integrated into the common psycho- dynamic model of migraine causation. Moreover, the methodological flaws that challenge the validity of these reports will be considered in detail. 13 mzmamoma 4h~4ogvn upwumo; «toe ueoaug mm opus ommp a uu3u1xsucu: Apsmpc «ocean A_~m_v mecca; x x x a m=_x .ctcu_;_m su__aeomtaa o>_w_=asou x x _o_ a mc_x .ctoe~;_m seem—s Aeoa_v ucoeowo a —wuzuox vacanwo a —_mzoaz x x x x ~ caspazm .Luceow suepmcomcoa m>em~3oeou .ommc «meager x < cue—35m .cwccmu x x x x x Awmo_c 0:.FLoam mc_Laocesou aaucaecmaauce.uoautaamaxo x x x x x x x x x MN Ammo—V oce_Laam mmwoea o>ucu x x x x Awmmpc mecoeLae mwmcou »_Fuuwcotzu "meowuuowc cameo oeocuxo o» mecca x x x x x x x x x x ooF “Nmo_c _xmcoeLze x x x x ~ Aommpc emucuxo—< x < Aomopc Loucmxmp< Amemsc Am¢m_c x x x x x u_o: a commzuco: wcsuww:_ nwmwaca m>ocu mumuocaocuco: ”omcmu x~_mu_:occu x x x x x x x x cm wwfio: a commaucoz Ameapc Ameo_v x x x cougmauzuz w mmom ovuoesmcuco: ”_ncowuco>:ou-gw>o x A x x x oom couzmzmzuz a mmox »u_Pwnwmcoamwc mcruuuoppm xu_=u_cmwu x x x x x Aummpc ww—oz w.voogv_wgu FoELoc. mm>_uwuwaeou ”sucovcoamv oewmme x x x x x x x x x we Ammo—c wwpo: :o_mmacnog mmmoeaoocm Aemm—c ucaocmxuon appEuc mw>wuwumasou ”mmc_Puac xuwcowemccw Aemm_v x x x x x cauEzuwmmueeace mcomcwa .vm>o_on. aggro» eucaFo>FnEa um>Fommeca x x x x x x m ccoezu_wx-EEoLu x x x x x smmmpc caocx ocwtao=_eoe mm>,u_ucav-ta>o ”magma »~.moscoaxu x J x x x x x on Ammmpv caoce Aemo.c “emote x x x x x cwnmco a meme=OF xucmucwnmv to mucouwo>a x x x x x om gunmen a oc_oL=o» x x x x x Acmm—c Loam: mucovwccOUTc—mm xo— x x x x _ Aemmpc Loam: mwmmmwwwm wwmmwumauuwwwwu Auava -13 .s L. 3 .l .m.% .H F m m.m m ,m u.“w 1w .0 m ammumm wm.1 Pu A1 asea aI.P um mJl.J .19 a as C 19 CITIJUVOILU 3 a S a auusuuumm 353 m Tm. wmwwufiunum as Lie 3 1 J l d :5: #22222 D 1. . aua P o u H P l «053 a l. n. .l 1: qupw 1. 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People who tell off directly have low fears of expressing anger (r = -.52) and few negative afterthoughts (r = .36). It is not pos- sible to make any of these predictions for people who say nasty things (r = -.03; r = -.06, respectively). People who tell off are generally more self-revealing about their feelings (r = +.l9) than are people who say nasty things (r = -.07), and tend to have higher self-esteem (r = +.l7) than 'nasty' people (r = -.19). People who say nasty things tend to have trait anxiety more consistently (r = +.26) than people who tell off other people directly (r = -.09), and they are easier to provoke (r - +.33; r = +.l4). nasty,provoke _ tell off, provoke People who express anger verbally by saying nasty things are also more likely to feel lasting resentment (r = +.49) than are people who tell someone off (r = +.09). People who say nasty things are also more likely to feel suspicious of others (r = +.30) than are people who verbalize anger directly (r = +.08). 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Ra. am.o_ m_ u 2 mm 1 z _ u m u 2 .F n z x882 888 o1m RP.P 54.. am. Ra. Ra. a u z em 1 2 P u a u 2 P u z spews um. a, um. mm. m u 2 NF 1 z o u m u 2 P u 2 saw a Pacm>mm mxunuu< mo chaaumgm 2....» e as 108 two symptoms of migraine (pseudo-migraine, N - 1723). Tension headache was the second most frequent diagnosis (N = 1029), while persons with head injuries made up the third largest group (N = 628). The fourth group was composed of people with no headache in the last year (N = 129), while the least common diagnosis was migraine headache (N = 107). These data provide a basic framework for examining avrious head- ache phenomena. First off, almost 96 per cent of the people sampled ex- perienced headache in the last year. It was relatively rare for an in- dividual to be headache-free for a lZ-month period (4.5%). Moreover, migraine headache was even less common (2.9%) than no headache at all. Tension headache was considerably more common than migraine (28.4%). However, almost half of the people sampled had headaches with one or two symptoms of migraine (47.6%), which means that there were more than 1-1/2 times more people with some of the symptoms of migraine than there were people with no migraine symptoms. More than one person in ten had a head injury that left them unconscious for a period of time (17.3%). Table 9A presents additional information about migraine symp- tomatology. Unilateral head pain was the most commonly reported migraine symptom in the total population (41.1%) and was reported by 64.7% of the pseudo-migraine groups. A sense of warning preceding the headache attack was reported by 27% of the total population, and 109 by 40.9% of the pseudo-migraine group. The most clear-cut symptom, nausea and vomiting, was the least frequently reported symptom (18.3%) by the total population and was reported by only 24.1% of the pseudo-migraine group. This rank ordering of migraine symptom- atology frequency was also apparent in the reports from people with head injuries and people having no headache in the last year. Re- ports from the no-headache group presumably indicated they experi- enced headaches with some of the migraine symptoms prior to the last year, and thus were not always headache-free. However, their head- aches tended to be mild and relatively unaccompanied by additional symptomatology. Of course, all of the “migraine“ §§_indicated having 100% of the symptoms, and none of the "tension" headache §§_reported any of the symptoms, as this was the criterion for diagnostic label- ing. Headache severity.--More than one-third of all §§_reported having severe or unbearable headaches (34.8%). However more migraine §§_reported having severe headaches than any other group (71%). Pseudo-migraine and head-injury‘§§.had about the same number of severe headache sufferers (41.8% and 38.2%, respectively), which was about half the frequency found among migraine Ss, Very few tension headache §§_reported having severe headaches (20%), indicating sever- ity to be one variable that distinguished migraine from tension 110 headache as tension headache was defined for this study. Results did not indicate whether this difference in severity referred to greater headache pain or to the additional disruption in living that migraine symptoms create. More than one person in ten who had not had a head- ache in the past year reported remembering a headache before that time that was severe or unbearable. Medical treatment for headache.—-In general, one person in seven sought treatment for headache at some time (14.2%). However, people in the migraine group sought medical treatment for their head- aches more frequently than any other group (40.2%). People in the pseudo-migraine and head-injury groups were equally likely to seek a physician's help for their headaches (16.5% and 17.7%, respectively), although both groups sought treatment far less frequently than did people with migraine. Relatively few §§_with tension headache saw a doctor for their headaches (6.8%), as was also true of the §§_hav- ing no headache in the last year (5.4%). Headache frequency.--Additional baCkground parameters of the headache groups are presented in Table 9A. Results indicate that having headaches daily or several a day was relatively rare (1.8%, total sample). About one-quarter of the population (25.6%) experi- enced a headache one to four times a week. Another quarter of the 111 population (24.3%) experienced a headache two or three times a month. Another 21.7% experienced a headache monthly or bi-monthly, while 27.0% had less than 6 headaches per year. In examining the distribution of headaches for each headache group, wide differences are apparent at some frequencies, while little differences appear at others. Almost all of the people who had no headache in the last year (94.9%) had less than 6 headaches in pre- vious years. In contrast, 44.9% of the migraine group had an average of one or more headaches per week. Neither the tension headache group (16.5%), nor the pseudo-migraine group (34%), nor the head- injury group (26.6%) reported as large an incidence of high headache frequency (1 or more a week), as the migraine group. Rather, these groups reported a preponderance of headaches occurring once a month or less (tension headaches = 59.2%; pseudo-migraine = 39.7%; head injury = 50.8%), in contrast to the migraine group (26.1%). All the headache groups reported approximately the same incidence of head- aches occurring 2 or 3 times per month. Sex composition.--Results in Table 9B indicate that the head— ache groups differed by sex composition, although the overall sample was balanced between males (48.1%) and females (51.9%). Migraine is about twice as common among females (65% of the migraine group) as among males. Pseudo-migraine §§_display the same predilection for 112 no.8 54.0 Rm._ am.N n_.mp manuaumag mm 1 _FF 1 z N u 2 am 1 4F 1 ma>wm merges R_.m Na Na wa.m N¢.m~ 88588888; em 1 mmF n z m u 2 mm 1 mu 1 a>_m mecca 5N.mm &¢.me Rm.e_ am.om Rem 88588888; _Nm 1 2 Re“ 1 2 mm 1 z epm u _m u ma>wm cam=< gm.wm No.me N©.__ No.8m RF.8m 88588888; New 1 2 mm“ 1 z m_ u z cam u on u m>wm msaxm mmcumumm; we mmmzmu No.8m gm.oo Ra.wm Np.me N¢.mm 0mm 1 z mach " 2 am 1 z woe u as u measaa Rm.mo xe.mm am._a Rm.Pm No.mm Nam u z mam u 2 No 1 2 4mm 1 mm 1 a_az cmucmo mmo u 2 mm“, 1 2 mm, 1 z 8N0, 1 No_ 1 m~mm a_asam xcawcH mcwmcmwz cum» awn; wsomcmm: msumvmm: azogw new: 1ou=mWQ . cowmcoh mcmmcmwz ovumocmmeo azumumm: oz mm u4m

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IJIIC< 41‘ 111-14(11 ‘ '. @OOOOOIFZOF}. ama mI-N m.....yww3 awn H «.....Muwm mun «1m Moooooxmwr awn Olm m.....>Jqu “.....wqm « Uflvu1mm 1. .........mwtuuzmaomam woqam>< abo> mH F413 m WMIU F3034 HDFUOO d QMFJDWZOU Qm>w 30> m>MIHmHWH UH 1>UZ 30> oHo .mmIququ Fuaoz. a:o> 04: 30> zwlz m HtHa ; . 1 : 1&IF wflOEH Q UD WOHW M7,)! >JHO 70 OMFGUOJ mmlU MUM? d . MUM. m-z: no urm>mm mmxuqoqm: kmaon a30> mamr m www-mxfimwcflflU,MFJJ1kflr Pfflfi? JG???“ CGMI «1Pcl LUDPIDUF Whml W Yfim> FM M>qI H APPENDIX E PARTIAL PRESENTATION OF DATA FROM BIHLDORF, KING, AND PARNES (197T) 217 [DATA COLLAPSED FOR PRESENTATION] "After I get angry at someone, I can 't stop thinking about what I wish I had said or done" Agree Can't Say Disagree Migraine (N = 33) 57.6% 6. l% 36.4% Tension (N = 41) 78.1 2.0 19.5 Controls (N = 27) 48.l 0.0 5l.8 x2 p = .02 "When I express my anger, I feel afterward I was wrong? Agree Can't Say Disagree Migraine 24.2% 15.2% 60.7 Tension 36.6 19.5 43.9 Controls 14.8 14.8 70.3 x2 p = .03 "In general. how comfortable are you in expressing your feelings of anger directly to other people?" Comfortable Uncomfortable Migraine 2l.3% 78.7 Tension 22.0 78.0 Controls 66.6 33.4 x2 p = .002 APPENDIX F CODEBOOK OF PERSONALITY AND BACKGROUND SCALES Minor Matrix 2 Var # Var ._a_a donooowmman—a ...-l—J—l—l—J—l—lo—l mmwmmhwm NNNN (ADM—'0 NNNNNN fiOCDNOSU'l-h wwwww th—‘o 218 MINOR MATRIX 2 CODE BOOK Description Headache in the last year Head injury Severe or unbearable headache Unilateral pain Vomit/Nausea Warning Consult doctor Frequency of headache General feeling Gender Exams give headaches Anger gives headaches Foods give headaches Dating gives headaches Age Racial background Class standing Terms at M.S.U. Parents' marital status Family income Verbal aggression Physical aggression Negativism Resentment Suspicion Fear of expressing anger Negative afterthoughts Rigidity Parental attachment Self-revelation Trait anxiety Work endurance Sexual experience Dating experience 219 MINOR MATRIX 2 CODE BOOK (cont‘d.) Minor Matrix 2 Var # Var 35 36 37 38 39 40 41 42 43 44 45 47 48 49 50 51 52 53 54 Description Self-concept Morality Parental discipline Minor chance annoyance Self-opinionated people Interpersonal encounters Criticism Total provocation Tell off (verbal aggression) Nasty (verbal aggression) Hit things (physical aggression) Trait anxiety (NEG indeces) Traint anxiety (POS indeces) Mother discipline Father discipline Omit Migraine-index Pseudo-migraine index (less than all three traits reported) Sex-by-migraine interaction index APPENDIX G ADDITIONAL DATA FROM THE PRESENT STUDY 220 BREAKDOM/N B \ O O. ) ) 2 X 2 VAaAH-‘xcas 221 C\UST¢\‘ Sus‘pickofi M'xgx‘aimz Tans Tom mad a {Yamaha m 2A 2 DC¢\\\A\ a. cha‘c \7‘5 \75 24.7") $¢V¢V¢ \ ‘39 \ 50 $2: LSS . \\O\\‘ §;\'S\ \WOD‘ . .. $0.\/¢\‘¢_ ) 38 \ Q5 Sax/arc: \' SO \A\j S? : )48 Q: \57 §= ((98 §= \55 321L148 C\U5Tac S¢V¢V¢ hOfi‘ S 41ch (“a 7 222 \\\ Qqa‘) lV/A 5%Tar+\\ouq\\’rs C) U \V\{q(a.im¢. ..— C.) ma\¢ 2.3 ' iamada. i :2,\S \98 SM“ 2.02 32: 2.17 K Y : é) q :2 .03 2 .05 S 232:4. § : 2.0\ ”209 T¢h$iom man \97 fima} a: \96 Q: \97 \ 93 was ' \88 we §:\.92 {3: \9A, 223 C\US*¢F Q VGA? 05 ¢XPVCS~SIWQ ahqax’ Miécblhe ' T¢fi$)0<\ mb\a , famb\(b ma\¢, gcxner, ‘>‘<:2.o\ » GVCl/i’e ‘ V¢¢¢ " S 2.15 \87 ‘3‘” 1.79 (.77 mm. 173 1 1.88 .255... 1.75 (79 ;=\.7« 7:94 ‘ 7:188 7=\.7(0 ;:\,7g 224 085(2):---8 R‘é‘MV MTQCthz C) ma) 0- f¢m\ 6L ;; 2.02 vad—qu 2% 204) Stu/arc. 8232?; 2 .35 2' O7 S 23;“; Y8: 2. \2 Tan 5(O\\ (\Wa\¢ £¢ma\ ¢ 2 \A 2.05 7:205 95 \93 H94 05‘ {74.98 C :20) XI 225 C. \ U SJTZA" 9 Paran*a\ afiadmx-w mnAV Mx'cgaina; T¢ns§on CJ m2»\C?— fttnfi5\¢ rmaAc. f¢\ha\¢ \ 9 SLV¢V¢ )51—2) \83 7: '6 S¢V¢C¢ Y:\.G>Cp bore. )7?» \58 .2522; ’ 7:164 Y=\-7\ - = ((07 \GZ \@ SZ:\.C0<\Z )49 \58 §=\.S‘i 74.92 226 Q\U$\¢V5 \\ Tcaik Amway, 27 T‘\\é\\ \md§c€t$ 28 L OVV {a c3- ; LCS C\QSJ)¢\T )\ TVb‘fi 50564))? 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CH ‘I‘O'o Y: O \\ X : O \O YL0.0S YLOOA “ i: 0.05 APPENDIX H QUESTIONNAIRE MATERIALS USED IN SAMPLING OF NEW YORK UNIVERSITY STUDENTS, MERIDIAN MALL §_§_, COMUNITY MENTAL HEALTH CENTER §_§_, AND M.S.U. COUNSELING CENTER §§_. MICHIGAN STATE UNIVERSITY 245 DEPARTMENT OF PSYCHOI OGY I'IAS'I' LANSING ‘ MICHIGAN ' 48824 01.05 "Al 1. Dear New York University Student: You are being asked to participate in a major research effort that may directly lead to better treatment of a universal problem: HEADACHES. The Department of Psychology at Michigan State University and a Federal Bio-Medical Research Grant are supporting a multi-campus study of headache incidence and life history. We are interested in finding out who has headaches, who doesn't, and why. Please give us one minute of your time to fill out our brief questions. Do not enter your_name or student number on this sheet. YOUR RESPONSES WILL REMAIN STRICTLY I OUS. A Profess ona Grummon gtrofes'sor John Hunter David M. Schna ch, M.A. Primary Investigator Department of Psychology epartment of Psychology '1. Have you had a headache within the last year?.................l 7ND 7 7§ES7 2. Have you ever had a head injury where you lost consciousness?.2 NO ES 3. Were your worst headaches severe or unbearable?...............3 N0 ES 4. Were your worst headaches located on only one side of your head (more than a momentary stab of pain)?...............4 N0 ES 5. When you had your worst headaches, did you vomit or feel nauseous (exclude time during pregnancy, if relevant)?........5 NO YES 6. Before you got your worst headaches, did you know they were coming?....O.......OOOCOOCCOCDOOOOOO0.0.0.0...0.0.0.4.....6 NO ’ IYES; 7. Have you ever consulted a doctor about your headaches?........7 NO YES 8. What is your average frequency of headaches? (Check one) several a day...............1 7 7 l per week..................5 / 7 daiIYOOOOIOIOOO0.00.0.0.0...2 I; ; 2-3 per monthOOOOOOOOIOOOOOO6 I ; 5-6 per week................3 7 7 1 monthly or bimonthly......7 7 7 2-4 per week................4 7 7 less than 6 per year........8 7 7 9. How do you feel most of the time? (Check one) very relaxed & happy............1 /__7 somewhat tense & upset.........4 somewhat relaxed & happy........2 Z__] very tense & upset.............5 neither relaxed & happy, nor tense & upset...............3 .£::7 J1 10. Your Bu?........l...............IOOOOOOOO0.0.0.000...00............ IMALE/ ’FME/ Do you associate your headaches with any of the following events:? /YEs7 12. Getting angrY?OOOOOOOOOO......OOOOOO......OOOO...0.0.0.0....12 /NO/ IYEJI 13. Eating particular foods?....................................13 /Ifl)7 /YES7 14. Going onadate?...........OOOOOOOOOOOOOOOOO0.00.00.00.0000014 /NO/ /YES; 1.1. Preparing for exan‘S?OOOOOOOOO......OOOOOOOOOOOOOO00......0.011 lNO/ ‘ ; ”1| '«z S"Y mum AN \lAll LNIVIR II 246 HI PARISH-NI HI- l’.\\('IIUIU(.\ I'.-\\l II\N\I.\(. ' .\II( I||(.A.\ ' "Us.“ 0| IDS “Al I DEBRIEFING STATEMENT The questionnaire you have just completed is part of a larger study, seeking to assess the role of personality in migraine causation. A migraine headache results from the dilation and contraction of the arteries in the skull. Tension headache, in comparison, results from the contraction of the muscles in the face, head, and neck. Migraine is generally more severe and less common. When the data from 5,000 students at Michigan State University were analyzed, ‘we found that migraine incidence was about one percent. This was surprising because the research literature predicted an incidence of between five and eight percent. Thus, the rate of migraine incidence among students at other campuses became of interest to us. Your responses to the questionnaire will allow us to diagnose the type of headache you have. Migraine is best identified by the presence of three symptoms: warning of impending headaches thru "prodromal symptoms;" unilateral head pain; and vomiting or nausea accompanying the headache. ‘Ss who have incurred severe head injury may show these symptoms in headaches due to organic damage, and thus are eliminated from the migraine-diagnOsed group. .§§ in the Michigan State University sample were also asked to complete a 109 item personality inventory. The personality dimensions and background history collected in the inventory were specially selected to tap areas relevant to the psychoanalytic model of migraine, which suggests that Inigraine is triggered by chronic repression of anger. The last four questions you answered today are related to the larger inventory, albeit somewhat more general. This information will eventually allow us to assess the role of personality in migraine causation. At the present time, the predominant modes of migraine treatment are chemotherapy and psychotherapy. Some initial attempts at bio-feedback training have shown promise. If our research can finally establish the personality profiles of migrainous and non-migrainous people, it is possible that the results can suggest whether personality-based forms of treatment are appropriate. MICHIGAN STATE UNIVERSITY 247 DEPARTMENT OF PSYCHOLOGY EAST LANSING ' MICHIGAN ° 48824 (MDSNAH Dear Citizen: We need two minutes of your time to help us learn about HEADACHES and their causes. This research is being done by scientists at Michigan State University. Over 5,000 people have already done their part in this study. Now we are asking you to answer a few brief questions about your own experience with headaches. DO NOT PUT YOUR NAME ON THIS SHEET. No one will be able to identify your answers. Your help will be greatly I Eé/é‘7LZEPL/ Pr essor John Hunter D partment of Psychology When you are done, place your sheet in the box provided. appreciated. Davi M. SchnafCh, M.A. Professor’Donald Grummon Primary Investigator Department of Psychology . Have you had a headache within the last year?.....................l IK)/ /YES/ . Have you ever had a head injury where you lost con8c1ou8ne88?0000.....IOOOOOOOO......OOOOOOOOOCOOO00.0.00...0.0.02 1N0, NBS, . Were your worst headaches severe or unbearable?...................3 /lK)/ lYES/ . Were your worst headaches located on only one side of your head (more than a momentary stab of pain)?........................4. /lK)/ [YES] 5. When you had your worst headaches, did you vomit or feel nauseous (exclude time during pregnancy, if relevant)?............5 NO [YES7 6. Before you got your worst headaches, did you know they were coming?l...l.0.00.00.00.0000............OOOOOOOOOOGOOOOO0.0.06 INOI IYES/ Have you ever consulted a doctor about your headaches?............7 (Check one) lper weeROOOOOCOOOOOOOOOS What is your average frequency of headaches? several a day...............1 / / \ [2 M U! \ ED IE dailYQOoooooooooooooooooooooz / / 2-3 per monthooooooooooooé 5-6 per week................3 / / 1 monthly or bimonthly...7 / / 2-4 per week................4 / / less than 6 per year.....8 / / 9. How do you feel most of the time? gCheck one) very relaxed & happy........1 / / somewhat tense & upset...4 / / somewhat relaxed & happy....2 / / 'very tense & upset.......5 / I neither relaxed & happy, nor tense & upset...........3 / 7 10. Your BeX?OOOOOOOOO......COOOCCOOOOCCOOOO00............OCCOOOOOOOOOO IMAI'E/ lFmALEfl Do you associate your headaches with any of the following events?: 12. 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Na. amae. came.a Names. maom.a coauaamsm ..aa. aa. me. name. oomo.a moae. mesa.a peasacamma ...ea. ea. am. comm. maaw.a owes. Naea.N ammuauca .moac aamaxca Santa so. M.. Na. aaas. ammm.a memo. mama.a ammuauca .mmcv aaoaxca Santa ..oa. ca. ma. amam. anam.a mass. eoea.a aumaxea pasta mo. mo. ac. maam. seem.a ommm. mee¢.a «caaaaumae assume ..aa. ea. ma. aame. aamm.a mmam. mmme.a «caaaaumau Lasso: ..aa. ea. ma. maae.. seem.a mesa. amo¢.a «caaaaumae aaaeoama see. we. as. mmam.. eaca.a amae. asmm.a magmsogatmaaa u>aaasmz me. mo. as. mama. moea.a mama. aamm.a tomes meammutaxm as race so. so. as. seam. am¢¢.a amae. ease.a smasauammz «ac. no. me. mama. moan.a moon. amm¢.a aaaooa “a: a.u.a=ouc m uamca xaozuaa< 252 Results indicate that the severe and non-severe headache groups differed with regard to several background variables, rendering them non-equivalent for comparison purposes. In examining the correlations corrected for attenuation (middle column), severe headache §§_were found to have a significantly higher frequency of headaches (r = +.26, p < .OOI), and a lower sense of well-being (r = -.l0, p < .Ol) than non-severe headache §§, Likewise, severe headache §§_were more likely to have consulted a doctor for headache treatment (r = +.33, p < .001) than §§_with mild headaches, and were also more likely to be female (r = -.08, p < .05). While the actual magnitude of these differences is extremely small, each stands as a potential intervening variable or competing explanation for any personality differences that may also exist between severe headache and mild headache §§, Therefore, these four significantly different background variables were partialled out from the correlations of headache severity with personality character- istics. These correlations, corrected for attenuation and partialled, appear in the right hand column of Appendix Table 3. Appendix Table 3 reveals that numerous personality traits do vary with headache severity. Severe headache §§_are significantly more readily provoked to anger (r = +.09, p < .01) than §§_with mild headaches. This finding may indicate that increased irritability may be a function of increased strain from severe headaches. Although 253 r does not indicate causality, the additional finding that severe head- ache §§_have more trait anxiety (r = .10, p < .Ol) tends to support this interpretation. Severe headache §§_were also significantly more likely to ex- press their anger in both verbal and physical means (r = +.09, p < .01, r = +.09, p < .01; respectively) than mild headache Sg, Specifically, the former group was more likely to resort to saying nasty things (r = +.ll, p < .Ol), hitting inanimate objects (r = +.08, p < .05) and hitting people (r = +.O7, p < .05), although they were no more likely to tell someone off directly (r = +.03, n.s.) than mild headache §§, Severe headache §§_had more negative afterthoughts after expressing their anger than did mild headache §§_(r = +.06, p < .05), although groups were found not to differ significantly in fear of expressing anger (r = +.03, n.s.). This latter pair of findings may indicate that severe headache §§_regret the particular style of expressing anger they are more prone to use (ie: saying nasty things to people and hitting them), rather than particular fears about the expression of anger, per se. Severe headache people are significantly more likely to report that their mother used withdrawal of love asia disciplinary technique than are mild headache §§_(r = +.l4, p < .001). Severe headache §§_ Were also significantly more suspicious of other people than were mild 254 headache §§_(r = + .09, p < .Ol). The meaning of these findings is not immediately clear. Prototypic experiences with mother might cause severe headache §§_to have higher anticipation of rejection from others. When the anticipated rejection is not forthcoming from current friends, severe headache §§_may become dubious and untrust- ing of friendliness. 0n the other hand, if this speculation about the impact of prototypic interactions with mother is true, then children of “withdrawing" mothers should also exhibit a 19! frequency of anger expression behaviors. Thus, this line of interpretation has its own logical flaws in explaining the results. Severe headache §§_also reported significantly stronger par- ental attachment than mild headache §§_(r = +.l5, p < .001). The former groups also reported having more sexual contact (r = +.lO, p< .Ol). If strong parental attachments generate guilt and con- flict in people who are engaging in sexual contact, it would tend to explain the finding that severe headache §§_have more trait anxiety than mild headache Sg, In another aspect, severe headache §§_were found to be sig- nificantly more resentful of the success and happiness of others (r = +.ll, p < .01) than mild headache S5, Moreover, the former group of §§_lead significantly more rigid and restricted life styles (r = +.09, p < .Ol). Thus the lifestyle of severe headache §§_may 255 exclude some of the experiences they covet in other people's lives. . Recalling that severe headache §§_were found to be more easily provoked to anger than mild headache S5, severe headache Sg, also reported significantly stronger tendency for anger to give them headaches than did mild headache §§_(r = +.09, p < .Ol). This find- ing is interesting in that severe headache §§_express their anger in significantly more ways than mild headache Sg, and yet they get sig- nificantly more headache from getting angry than do mild headache §§, If the psychoanalytic theory that migraine and tension headaches are caused by repression and suppression of anger (respectively) is true, severe headache §§ should generally express 1§§§_anger than mild headache §§, However, this assumption is not supported by the data. Severe headache §§_were also found to get more headaches from dating (r = +.O7, p < .05) and foods (r = +.lO, p < .Ol) than mild headache Sg, However, these groups were found not to differ with respect to examinations causing headaches (r +.03, n.s.). While results indicate numerous statistically significant personality differences between people with severe and mild headaches, the magnitude of the differences was extremely small. The differences between severe and non-severe headache §§_are presented visually in Figures 8-Zl. Thus, while severity”seems to have an impact on person- ality, it seems to be a rather minor one. 256 Severe Headache vs. Non-Severe L, Headache i u—I-c '1 '1‘ i i = 2.66 ‘3 °'- .518‘+ Grand Mean = 2.6l _L l J 1 2 3 i- 2.57 0 - .5126 Severe Headache ...-I... “h p—J... Non-Severe Headache FIG. 8.--Differences between severe and non-severe headache §§ in anger provoked by items assessed in the Provocation Scale. savers Headache Some Almost vs. Times Always Non-severe L_, I d I J . Severe Headache I Ti I I Headache 1 2 '3 u >-<-2.1t+ 0 = .5698 Grand Mean = 2.00 1 Non- frs h { I Severe 1 2 3 u Headache X - 2.06 0 - .5199 FIG. 9.--Differences between severe and non-severe headache §§_in trait anxiety. 257 Almost Almost Never Always | f i _ Severe Headache 1 2 3 )7-1.63 ° - .3932 Grand Mean = 1.79 Non-Severe Headache L L l l T' l 1 2 9 X - 1.77 0 - .uoau FIG. l0. --Differences between severe and non-severe headache Ss in verbal expression of anger. Severe Headache Almost Almost vs. Never Always an-Severe I J 1 l Severe Headache Headhahe j—_ I 1 2 3 i -1.98 0 - 0.63 Grand Mean = 1.35 l L i { Non-Severe Headache 7-1.31 a - 0.61~ FIG. ll.--Differences between severe and non-severe headache S_s in physical expression of anger. 258 Almost Almost Never L Always l I [ Severe Headache 1 2 3 X - 1.99 ° " .u931 Grand Mean l.93 I [i I Non-Severe Headache 1 2 3 X 1.90 O_ .5133 FIG. lZ.--Differences between severe and non-severe headache §§,in negative afterthoughts. severe Almost Almost gjadache Never Always Severe Headache Non-Severe I L i . { Headache 1 2 3 X — 1.46 0 - .1148? Grand Mean + 1.41 Non-Severe Headache l l I 1 1 2 3 X 1.35 a _ .u201 FIG. l3.--Differences between severe and non-severe headache .Sg in parental use of withdrawal of love as a disciplinary technique. 259 Severe Almost Almost Headache Never 3 Always vs. , j Severe Headache Non-severe I if [ Headache 1 .2 3 i - 1.69 0 - .9113 Grand Mean = 1.60 I I *1 ii Non-Severe Headache 1 2 3 5? - 1.6k 0‘ - .3936 FIG. l4.--Differences between severe and non-severe headache _S_s_ in parental attachment. severe Almost Almost Headache Never Always vs. ‘ Non-Severe I l % i Severe Headache Headache 1 2 3 >-( - 1.1.1 0 - .3502 Grand Mean 1.35 | J 4— i Non-Severe Headache 1 2 . 3 i - 1.39 0 - .3668 FIG. lS.--Differences between severe and non-severe headache _Si in sexual experience. 260 Almost Almost Never Always I ' w. : 1 2 3 X-1.60 ° - .9939 Grand Mean l.53 I11 1 1 2 3 X '1.99 0 - .9162 Severe Headache Non-severe Headache FIG. lG.--Differences between severe and non-severe headache S5 in suspicion of others. severe Almost Almost Headache Never Always ‘08. L Hen-severe I t I Headache 1 2 3 i- 1.76 0 - .9219 Grand Mean 3 l.74 3? - 1.71 a - .9326 'Severe.Headache Non-Severe Headache FIG. l7.--Differences between severe and non-severe headache §§_in feelings of resentment. 261 Almost Almost Never Always I II I Severe Headache 1 2 3 X “2.06 ° " .5077 Grand Mean l.98 I II I Non-Severe Headache 1 2 3 X - 1.99 0 = .5563 FIG. l8.--Differences between severe and non-severe headache §§_in rigidity of lifestyle. Severe No Yes Headache I vs. I I I Severe Headache Non-severe 1 2 3 Headache Q X - 0.99 0 - .9969 Grand Mean 0.38 I J “I I Non-severe Headache 1 2 3 X - 0.36 0 - .9592 FIG. l9.--Differences between severe and non-severe headache §§_in anger Causing headaches. 262 Severe No Yes Headache 1 vs. I I I Severe Headache Non-Severe 0 1 Headache - X = 0.10 0 = .2630 Grand Mean = 0.05 l ' Non-Severe Headache FIG. 20.--Differences between severe and non—severe headache §§ in dating causing headaches. Severe No Yes Headache I vs. I ”J I I Severe Headache Non-Severe 1 3 I Headache - X = 0.17 0 - .3921 Grand Mean = 0.08 I [ ~I I Non-Severe Headache X=0.10 0 .2259 FIG. Zl.--Differences between severe and non-severe headache .§§ in particular foods causing headaches. 263 Relation of Personality and Sex Differences The impact of sex differences on personality traits among tension and migraine headache §§_was explored. The correlations of sex with personality traits are presented in Appendix Table Four. As can be seen in the correlations corrected for attenuation (middle column) in Table l5, males and females differed significantly on a number of background variables. Specifically, females reported significantly more frequent headaches (r = «.15, p < .001) and head- aches of greater severity (r = -.08, p < .05) than did male §§, Fe- males were also significantly more likely to have consulted a doctor for their headaches (r = -.07, p < .05). Moreover, females were significantly younger in age (r = -.lO, p < .01) and had achieved less academic rank (ie: freshman or sophomore standing) than male §§_(r = ~.09, p < .01). Each of these differences, particularly those of frequency and severity of headache, could have their own additive impact on personality differences, beyond the effects of sex differences. Thus, the effects of these background variables were partialled out by statistical means to allow more equivalent comparisons of the personality of male and female headache §§, The correlations, corrected for attenuation and partialled, appear in the extreme right hand column of Appendix Table Four. 264 mo. No. No. Rom. _e.P P_m. mm._ mesmeogptseas s>eceesz ..oo.. . No.- Fo.- gee. om.e owe. 0N.P emcee meemmmtexs e662 .««_P. ..mo. so. mam. ee._ woe. we._ sme>ep6mcz ...¢_. ..«m_. PP. wee. mm.P cam. m¢._ c_eose SP: «so. me. co. New. m~._ men. ~M._ mm=_;p ea: .¢«~_. .«o_. mo. 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