Introduction
The period related to lockdown has profoundly influenced our way of life, increasing feelings of anxiety, depressive experiences and loneliness (Giallonardo et al. 2020). This could have had a psychological impact on adolescents, especially on those who have an underlying medical condition.
The five-factor model, also known as the Big Five, is a well-known psychological theory that allows one to identify individual differences in the construction of personality. It uses 5 personality macro-categories which describe different personality profiles (Costa et al. 2012). Categories are: extraversion (for sociability, assertiveness, level of activity, dynamism); agreeableness (for altruism, caring, cooperativeness); conscientiousness (for capacity for self-regulation, accuracy, scrupulousness, perseverance); neuroticism or emotional lability (for inability to control emotional reactions, mood instability, presence of negative affectivity and irritation); and openness (for openness to novelty, broad cultural interests, creativity). The Big Five profiles can be considered risk factors or protective factors for mental disorders such as anxiety.
Population studies on headache have identified high levels of neuroticism as a risk factor, while high levels of extroversion, agreeableness and conscientiousness appear to be protective for the development of headache (Magyar et al. 2017).
The aim of our study was to characterize the psychological profile of an adolescent group with headache, using the Big Five dimension, before the outbreak of the COVID-19 pandemic and how these traits underwent changes after the social isolation imposed during 2020. We took into consideration protective factors, such as the presence of a coping strategy, friendships, relation with parents, and risk factors related to coexisting psychopathologies, school difficulties and bullying.
Material and methods
Population
The sample is composed of adolescent neurological outpatients who came to our clinic reporting headache and who voluntarily adhered to the psychological evaluation carried out between March and April 2019 and repeated in June 2020.
Evaluation
In March-April 2019, before the COVID-19 outbreak, we collected personal information about 40 patients complaining of headaches, regarding: age, sex, headache, Big Five levels, psychiatric comorbidity, presence of coping strategies such as sports and reading. Headache was classified according to the third International Classification of Headache Disorders and divided into three macro-categories (migraine, tensive and somatoform). The assessments included the Big Five Inventory (BFI) for psychological dimensions: this is a self-report questionary using a 5-point Likert scale to obtain a final score; higher scores indicate higher levels of a given personality trait; the Italian version of the scale, for this population, was also validated (Fossati et al. 2011). Psychiatric comorbidities were evaluated using the Child Behavior Checklist by Achenbach (CBCL6/18), a self-report questionnaire from which it is possible to determine the overall functioning of the child through the “Internalization” scale, which includes anxiety, depression and somatic grievances, and the “Externalization” scale that measures aggressive behavior and rule breaking.
About a year after the assessment, in the period between June and August 2020, the BFI was repeated.
Finally, through structured interviews, before and after lockdown we investigated presence of other environmental factors: use of social networks, friendships, relation with parents, perception of school difficulties and bullying.
Conscious consent
Participation in the study was voluntary and no financial compensation was given to the recruited participants; all the participants expressed their informed consent to obtain the data. The study respects the bioethical criteria for scientific research.
Statistical analysis
Data regarding continuous variables such as the factors of the Big Five model were reported as median and interquartile range (IQR).
The Wilcoxon signed-rank test was used to evaluate the differences for factors of the Big Five model between the two periods.
Results
The final sample, from the initial group of 40 patients, included 15 patients (12 females and 3 males), with a mean age of 16 years (max. 18 years, min. 13 years) who agreed to repeat the evaluation after one year; of these, 7 suffered from tension-type headache (including 6 females and 1 male), 5 from migraines with aura (3 females and 2 males) and 3 females from somatization headache.
From CBCL6/18 analysis we found that 6 patients were clinical for internalizing problems, 1 was clinical for internalizing and externalizing problems and 4 girls had a borderline score for psychological problems. In our sample 4 patients were without clinical scores (Table 1).
As regards BFI scores, we analyzed the mean score changes in our sample from the pre-COVID to post-COVID period and we obtained the following results: extraversion scores changed from a mean of 25 in the pre-COVID (IQR 19-30) to a mean of 24 in the post-COVID period (IQR 21-29), agreeableness changed from 34 (IQR 27-36) to 33 (IQR 30-38), conscientiousness from 30 (IQR 22-25) to 31 (IQR 25-38); neuroticism from 28 (IQR 21-32) to 29 (IQR 22-31) and openness from 36 (IQR 24-41) to 35 (IQR 29-43). Conscientiousness had a significant improvement (p-value = 0.0269). The other categories of the Big Five theory had no statistically significant mean differences between the two periods (Table 2). The difference in conscientiousness values before and during the lockdown remains significant when considering only the female subgroup (p-value = 0.02).
Finally, it appears that in the environmental factors only perception of school difficulties and bullying had an improving trend during the COVID-19 period, while other environmental factors were equally present in the two periods: 11 patients reported improvements in academic performance (3 did not report previous school difficulties, 1 stopped school attendance); 10 patients reported a reduction in cases of bullying and 4 never experienced one. Protective factors were equally present in the two periods (see Table 1).
Discussion
Conscientiousness is considered a positive behaviour, which usually includes qualities such as scrupulousness, organizational capacities and motivation to complete an assigned task. It results in working hard and willingly, doing the best without being stressed (Barbaranelli et al. 1998).
Among factors could have influenced the increase of conscientiousness, it is possible to identify a trend only concerning the decrease in scholastic difficulties and bullying episodes; improvement of these factors is temporally related to the transition from traditional face-to-face teaching to remote teaching.
It is possible to compare our findings to other studies that investigated how the COVID-19 period influenced mental health of adolescents. In particular, research conducted on a population of adolescents suffering from somatoform disorders has revealed an improvement in the emotional aspects during the lockdown (De Nardi et al. 2021). In this study it was recorded that the reduction of stressors was linked to the teaching change. With the transition from traditional teaching to remote teaching, the school setting undergoes changes, especially for what concerns the relational component, which is inevitably reduced.
Conscientiousness is a dimension including skills such as self-regulation, precision, accuracy, scrupulousness, tenacity, and perseverance, that emerge especially in a performing environment. So, we believe that participants in our study, after being exposed to a reduction in bullying and relational conflicts, may have perceived a less competitive and more welcoming school environment, also leading to an improvement in their academic performance.
Due to the small sample size, it was not possible to establish statistically significant correlations or to infer causality relations. Nevertheless, we can hypothesize that adolescent patients suffering from headache have personality characteristics which are susceptible to emotional, relational and performance aspects, especially expressed in school.
Conclusions
The emerging results of our study demonstrate an unexpected improvement in a personality trait considered positive, during a period of high traumatic value and which correlates with an increase in mental distress in developmental age (Jones et al. 2021).
The strength of our study remains the comparison between the pre-COVID period and the one immediately following the lockdown. Unfortunately, the small number of participants in our research hardly allows us to make deductions applicable to the general population. Nevertheless, we can hypothesize that adolescent patients suffering from headache have personality characteristics which are susceptible to emotional, relational and performance aspects, especially expressed in school. We hope that our study has established a basis for further research to support our findings, researching how personality traits can change in these patients due to environmental factors, comparing them to a control group.
Disclosure
The authors declare no conflict of interest.
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