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Coping with emotions and abuse history in women with chronic pelvic pain
Journal of Psychosomatic Research 60 (2006) 109 – 112
Coping with emotions and abuse history in women with chronic pelvic pain Ethne Thomasa, Rona Moss-Morrisa,T, Cindy Faquharb b
a Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
Received 25 May 2004; accepted 19 April 2005
Abstract Objective: The purpose of this study was to investigate whether past abuse and the tendency to repress or suppress unwanted thoughts and emotions contribute to the experience of pain in patients with chronic pelvic pain (CPP). Methods: A group of CPP patients without endometriosis and a group with endometriosis were compared with a pain-free control group. Participants completed measures of pain, emotional repression, suppression of unwanted thoughts and emotions, and past abuse history. Results: Both CPP groups were more likely to be emotional suppressors
when compared with the control group and reported significantly higher levels of thought suppression and abuse. Endometriosis patients were also more likely to be repressors of emotions when compared with controls. Suppression but not repression was related to higher levels of abuse and pain. Conclusion: Suppression of unwanted thoughts and emotions and past abuse distinguishes CPP patients from healthy controls. Assisting patients to express distressing emotions may impact on pain levels. D 2006 Elsevier Inc. All rights reserved.
Keywords: Abuse; Chronic pelvic pain; Endometriosis; Repression; Suppression; Anger-in
Introduction People with chronic pelvic pain (CPP) experience ongoing pain that may worsen around the time of menstruation and during sexual activity [1]. The pathology most commonly found to explain CPP is endometriosis, where endometrial tissue develops outside the lining of the uterus [2]. There are also patients who have no obvious evidence of pelvic pathology to explain their symptoms [3]. In this paper, these patients are referred to having CPP without endometriosis. CPP has been associated with a lifetime incidence of physical and sexual abuse [4– 8]. The purpose of this paper is to investigate whether maladaptive ways of coping with T Corresponding author. Department of Psychological Medicine, The Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92 019, Auckland, New Zealand. E-mail address: [email protected] (R. Moss-Morris). 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2005.04.011
emotions may help to explain the link between abuse and CPP. Emotional coping styles that are thought to be maladaptive in the long term include repression, the defensive denial of negative emotions, and suppression, the conscious effort to avoid distressing thoughts or expressing negative emotions for reasons of social desirability [9–12]. Emotional repression has been linked to medically aversive physiological changes [13–16], while suppression has been associated with the experience of medically unexplained somatic symptoms such as chronic fatigue and chronic back pain [9,17–19]. We therefore hypothesised that when compared with healthy controls, CPP patients without endometriosis would report significantly higher levels of suppression, while CPP patients with endometriosis would report higher levels of repression. We also predicted that both CPP groups would report higher levels of abuse when compared with controls and that repression and suppression will be related to reports of abuse and pain intensity.
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E. Thomas et al. / Journal of Psychosomatic Research 60 (2006) 109 – 112
Method Participants Ninety-eight female participants completed questionnaires for the study: 37 with endometriosis-related CPP, 24 with CPP without endometriosis, and 37 nonpain controls. The response rate for the CPP patients was 92%, with five patients declining to participate. CPP patients were recruited through a Pelvic Pain clinic after they had been diagnosed through laparoscopic investigation by one of two consultant gynaecologists as having either endometriosis, or CPP without endometriosis if there was little or no evidence of pathology to attribute to their pain condition. Non-pain controls were recruited from the community if they matched the demographic profile of the CPP groups and had no evidence of a current chronic illness or chronic pain. Table 1 shows that the groups were well matched for age, ethnicity, and marital status. There was no significant difference in the length of pain experienced between the two CPP groups. After providing informed consent, participants were given a coded questionnaire to maintain anonymity. The questionnaire was either filled in at the hospital or taken away and posted back to the researcher.
Marlowe-Crowne Scale of Social Desirability [23], which measures behaviour as a defence against social threat, and the Bendig short-form of the Taylor Manifest Anxiety Scale [24]. Both scales have excellent psychometric properties and have been used extensively in research on emotional repression [10,25]. Participants are classified as repressors (low anxious, high social desirability), suppressors (high anxious, high social desirability), high anxious (high anxious, low social desirability), and low anxious (low anxious, low social desirability). Thought suppression was measured using the White Bear Suppression Inventory [26]. This scale has good concurrent validity and measures conscious effort to avoid distressing, unwanted thoughts by focusing attention elsewhere [26]. The tendency to suppress angry feelings was measured using anger held in, a subscale of the State-Trait Anger Expression Inventory [27]. These items have been used as a valid measure of anger expression in chronic pain studies [27]. Retrospective reports of abuse were measured using the Sexual and Physical Abuse History Questionnaire [28]. This quantifies the types of sexual abuse and the frequency of physical abuse experienced in both childhood and adulthood. The questionnaire has been used as a valid measure in other pain populations [28,29].
Measures
Results
Pain was measured through a composite score of two visual analogues, which measured pain at the time of reporting and cyclic pain [20], and the four-item National Women’s Sexual Pain Scale, which measured pain associated with sexual arousal and intercourse. Visual analogues are valid and reliable measures of pain [21,22], and the National Women’s Sexual Pain Scale has good internal reliability. Emotional coping styles were measured in three different ways. Repression and associated categories were determined by the method of Weinberger et al. [11] of dividing individuals into groups based on median splits on the
Between-group differences on emotional coping styles The means, percentages, and inferential statistics used to compare the three participant groups across the emotional coping styles are listed in Table 2. A significant difference was found on all the coping styles. Chi square was used to compare the three groups across the four the Weinberger repression categories (see Table 2). Post hoc pairwise analyses showed that repression was significantly more prevalent in the endometriosis CPP group than in the other two groups. Suppression was more likely to be used by both the CPP groups than the control group.
Table 1 Demographic characteristics of the participant groups Variable Age Mean (S.D.) Ethnicity (%) Caucasian Maori Pacific Island Asian Marital status (%) Single Married/defacto Separated/divorced Years of CPP Mean (S.D.)
Endometriosis related CPP
CPP without endometriosis
Non-pain controls
Statistic
Probability
30.9 (8.6)
31.7 (6.2)
32.9 (8.7)
F(2,92) = 0.50
P =.601
81 6 6 6
81 14 5 0
86 6 3 5
v 2(6) = 4.59
P =.598
47 47 6
38 54 8
49 43 5
v 2(2) = 0.886
P =.927
8.65 (5.6)
6.12 (5.8)
na
t = 1.67
P = .100
E. Thomas et al. / Journal of Psychosomatic Research 60 (2006) 109–112 Table 2 Emotional coping styles and abuse history across participant groups Variable Coping styles Weinberger et al. categories (%) Repressors (%) Suppressors (%) High anxious (%) Low anxious (%) Thought suppression M (S.D.)
Endometriosis CPP without Non-pain related CPP endometriosis controls Statistic
v 2=24.68TTT
37.1 34.3 22.9
13.6 50.0 22.7
21.6 8.2 32.4
5.7
13.6
37.8
40.50 (17.70)
45.13 (23.28)
26.05 (14.54)
F=9.36TT
15.91 (3.97)
17.43 (3.98)
14.44 (3.06)
F=5.20T
Abuse history Lifetime sexual abuse Mean rank 51.18 Lifetime physical abuse Mean rank 46.38
63.44
34.14
v 2=17.65TT
64.02
38.69
v 2=13.37TT
Anger held in M (S.D.)
111
comparisons using Mann–Whitney U, with P=.017, showed that there were no significant differences between the two CPP groups on either form of sexual abuse. The CPP patients without endometriosis had significantly higher levels of both physical and sexual abuse when compared with nonpain controls, but the endometriosis group only differed from the controls on a history of sexual abuse. Relationships between emotional coping styles, abuse history, and pain
T Pb.01. TT Pb.005. TTT Pb.001.
Control participants were significantly more likely to fall into the low anxious/low social desirability group. ANOVA with post hoc Dunnett’s C tests were used to compare groups on thought suppression and anger held in. Both CPP groups used significantly more thought suppression than did the control group. CPP patients without endometriosis also reported higher levels of holding anger-in. Abuse history Reports of abuse histories across groups were compared using nonparametric Kruskal–Wallis tests. Table 2 shows that there were significant differences between the groups on both sexual and physical abuse. Post hoc pairwise
The next objective was to investigate whether emotional coping styles were associated with a history of abuse and pain. Comparisons of abuse across the Weinberger repression categories were made using Kruskal–Wallis, while pain was compared using ANOVA (see Table 3). Post hoc tests controlling for multiple comparisons showed that the suppressors were significantly more likely to report a history of physical abuse compared with the repressors and also reported more pain than did the other three groups. There were no differences between the other groups on levels of pain. Spearman’s rho and Pearson’s correlation coefficients were used to investigate the relationships between the self-report coping measures and abuse and pain. Thought suppression was related to physical (r s=.35, Pb.01) and sexual abuse (r s=.35 Pb.01), as was anger held in (r s=.26, P b.05 for physical abuse and r s=.37, P b.01 for sexual abuse). Both thought suppression (r=.41, Pb.01) and anger held-in (r=29, Pb.01).
Discussion The results support previous findings of an association between CPP and abuse [4–8]. This study is the first to suggest that CPP patients with and without endometriosis have a tendency to use ways of coping with past trauma and emotions such as suppression, which are thought to be maladaptive in the long term. Certain limitations of the study should be noted. The number of patients in each of the groups was relatively small. Abuse was measured using a self-report scale that has
Table 3 Comparisons of pain levels and abuse history across Weinberger and colleagues’ categories of repression Variable Pain Mean (S.D.) Lifetime sexual abuse Mean rank Lifetime physical abuse Mean rank T Pb.05. TT Pb.005.
Repressors (n=22)
Suppressors (n=25)
High anxious (n=25)
Low anxious (n=19)
Statistic
9.96 (6.63)
16.81 (5.8)
9.56 (8.44)
6.03 (4.88)
F(3,87) =10.41TT
44.00
53.54
47.13
36.17
v 2(3) =5.04
35.59
56.58
49.56
39.28
v 2(3) =10.21T
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E. Thomas et al. / Journal of Psychosomatic Research 60 (2006) 109 – 112
been linked to an underreporting of abuse [30], and the study was cross-sectional so the direction of the relationships between the variables cannot be established. Despite these limitations, most of the study’s hypotheses were supported. CPP patients without endometriosis showed a pattern similar to patients with other unexplained medical syndromes [17,18]. They had a tendency to suppress unwanted thoughts and emotions, including anger. Results for endometriosis patients were more mixed. Patients tended to be either repressors or suppressors of emotions, suggesting that this may be a more psychologically heterogeneous group. Holding in negative emotions and avoiding intrusive thoughts were related to pain intensity and a lifetime history of abuse. However, repression was not. It may be that repressors underreport pain and/or repress memories of abuse. More work is needed to understand the relationship between repression, physiological arousal, and endometriosis and how repressors cope with pain and a past history of negative events. This study has clinical implications for patients with CPP. From a psychological point of view, there appeared to be more similarities than differences between patients with a recognised medical diagnosis of CPP and those with an unexplained syndrome. Helping these patients express negative thoughts and emotions, particularly those related to past abuse may reduce pain experiences. It may be more difficult to identify the repressors, as they may deny experiencing negative feelings or past events. Future research should focus on identifying this group in a clinical context. Research should also include other chronic nonpelvic pain groups as controls to ascertain whether the findings are unique to CPP. References [1] Sand PK. Chronic pain syndromes of gynecologic origin. J Reprod Med 2004;49(3 Suppl):230 – 40. [2] Davis CJ, McMillan L. Pain in endometriosis: effectiveness of medical and surgical management. Curr Opin Obstet Gynecol 2003;15:507 – 12. [3] McGowan LPA, Clark-Carter DD, Pitts MK. Chronic pelvic pain: a meta-analytic review. Psychol Health 1998;13:937 – 51. [4] Heim C, Ehlert U, Hanker JP, Hellhammer DH. Abuse-related posttraumatic stress disorder and alterations of the hypothalamic– pituitary–adrenal axis in women with chronic pelvic pain. Psychosom Med 1998;60:309 – 18. [5] Walker EA, Katon WJ, Hansom J, Harrop-Griffiths J, Holm L, Jones ML, et al. Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain. Psychosomatics 1995;36:531 – 40. [6] Peters A, Van Dorst E, Jellis B, Van Zuuren E, Hermans J, Trimbos JB. A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. Obstet Gynecol 1991;77:740 – 4. [7] Rapkin AJ, Kames LD, Darke LL, Stampler FM, Naliboff BD. History of physical and sexual abuse in women with chronic pelvic pain. Obstet Gynecol 1990;76:92 – 6. [8] Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gynecol 1990;33:130 – 6.
[9] Burns JW, Johnson BJ, Devine J, Mahoney N, Pawl R. Anger management style and prediction of treatment outcome among male and female chronic pain patients. Behav Res Ther 1998; 36:1051 – 62. [10] Myers LM. Deceiving others or deceiving themselves? Psychologist 2000;13(8):400 – 3. [11] Weinberger DA, Schwartz GE, Davidson RJ. Low-anxious, high anxious and repressive coping styles: psychometric properties and behavioural responses to stress. J Abnorm Psychol 1979; 88:369 – 80. [12] Wegner DM, Schneider DJ, Knutson B, McMahon SR. Polluting consciousness: the effect of thought suppression and the mind’s environment. Cogn Ther Res 1991;15:141 – 52. [13] Brown LL, Tomarken AJ, Orth DN, Lossen PT, Kalin NH, Davidosn RJ. Individual differences in repressive-defensiveness predict basal salivary cortisol levels. J Pers Soc Psychol 1996;70:362 – 71. [14] Gross J. Emotional expression in cancer onset and progression. Soc Sci Med 1989;28:1239 – 48. [15] Jensen MR. Psychological factors predicting the course of breast cancer. J Pers 1987;55:317 – 42. [16] Kneier AW, Temoshok L. Repressive coping reactions in patients with malignant melanoma as compared to cardiovascular patients. J Psychosom Res 1984;28:145 – 55. [17] Creswell C, Chalder T. Defensive coping styles in chronic fatigue syndrome. J Psychosom Res 2001;51:607 – 10. [18] Cioffi D, Holloway J. Delayed costs of suppressed pain. J Pers Soc Psychol 1993;64:274 – 82. [19] Pang KYC. Hwabyung; the construction of a Korean popular illness among Korean elderly immigrant women in the United States. Cult Med Psychiatry 1990;14:495 – 512. [20] Fry RP, Beard RW, Crisp AH, McGuigan S. Sociopsychological factors in women with chronic pelvic pain with and without pelvic venous congestion. J Psychosom Res 1997;42:71 – 85. [21] McDowell I, Newell C. Measuring health. A guide to rating scales and questionnaires. New York7 Oxford Press, 1996. pp. 335 – 78. [22] Melzack R, Katz J. The McGill Pain Questionnaire: appraisal and current status. In: Turk DC, Melzack R, editors. Handbook of pain assessments. New York7 Guilford Press, 1992. pp. 52 – 168. [23] Crowne DP, Marlowe DA. A new scale of social desirability independent of psychopathology. J Consult Clin Psychol 1960; 24:349 – 54. [24] Bendig AW. The development of a short form of the manifest anxiety scale. J Consult Clin Psychol 1956;20:384. [25] Weinberger DA, Davidson MN. Styles of inhibiting emotional expression: distinguishing repressive coping from impression management. J Pers 1994;62:587 – 613. [26] Wegner DM, Zanakos S. Chronic thought suppression. J Pers 1994; 62:615 – 40. [27] Spielberger CD, Sydeman SJ, Owen AE, Marsh BJ. Measuring anxiety and anger with the State-Trait Anxiety Inventory (STAI) and the State-Trait Anger Expression Inventory (STAXI). In: Maruish ME, editor. The use of psychological testing for treatment and outcome assessment. Mahwah (NJ)7 Lawrence Erlbaum and Associates, 1989. pp. 993 – 1021. [28] Leserman J, Drossman DA, Zhiming L. The reliability and validity of a sexual and physical abuse history questionnaire in female patients with gastrointestinal disorders. Behav Med 1995;21:141 – 50. [29] Toomey TC, Seville JL, Mann JD, Abashian SW, Grant JR. Relationship of sexual and physical abuse to pain description, coping and psychological distress, and health-care utilization in a chronic pain sample. Clin J Pain 1995;11:307 – 15. [30] Williams LM, Siegel JA, Jackson PJ. Validity of women’s selfreports of documented child sexual-abuse. In: Stone AA, Turkkan J, editors. The science of self-report: implications for research and practice. Mahwah (NJ)7 Lawrence Erlbaum and Associates, 2000. pp. 211 – 26.
Coping with emotions and abuse history in women with chronic pelvic pain Ethne Thomasa, Rona Moss-Morrisa,T, Cindy Faquharb b
a Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
Received 25 May 2004; accepted 19 April 2005
Abstract Objective: The purpose of this study was to investigate whether past abuse and the tendency to repress or suppress unwanted thoughts and emotions contribute to the experience of pain in patients with chronic pelvic pain (CPP). Methods: A group of CPP patients without endometriosis and a group with endometriosis were compared with a pain-free control group. Participants completed measures of pain, emotional repression, suppression of unwanted thoughts and emotions, and past abuse history. Results: Both CPP groups were more likely to be emotional suppressors
when compared with the control group and reported significantly higher levels of thought suppression and abuse. Endometriosis patients were also more likely to be repressors of emotions when compared with controls. Suppression but not repression was related to higher levels of abuse and pain. Conclusion: Suppression of unwanted thoughts and emotions and past abuse distinguishes CPP patients from healthy controls. Assisting patients to express distressing emotions may impact on pain levels. D 2006 Elsevier Inc. All rights reserved.
Keywords: Abuse; Chronic pelvic pain; Endometriosis; Repression; Suppression; Anger-in
Introduction People with chronic pelvic pain (CPP) experience ongoing pain that may worsen around the time of menstruation and during sexual activity [1]. The pathology most commonly found to explain CPP is endometriosis, where endometrial tissue develops outside the lining of the uterus [2]. There are also patients who have no obvious evidence of pelvic pathology to explain their symptoms [3]. In this paper, these patients are referred to having CPP without endometriosis. CPP has been associated with a lifetime incidence of physical and sexual abuse [4– 8]. The purpose of this paper is to investigate whether maladaptive ways of coping with T Corresponding author. Department of Psychological Medicine, The Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92 019, Auckland, New Zealand. E-mail address: [email protected] (R. Moss-Morris). 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2005.04.011
emotions may help to explain the link between abuse and CPP. Emotional coping styles that are thought to be maladaptive in the long term include repression, the defensive denial of negative emotions, and suppression, the conscious effort to avoid distressing thoughts or expressing negative emotions for reasons of social desirability [9–12]. Emotional repression has been linked to medically aversive physiological changes [13–16], while suppression has been associated with the experience of medically unexplained somatic symptoms such as chronic fatigue and chronic back pain [9,17–19]. We therefore hypothesised that when compared with healthy controls, CPP patients without endometriosis would report significantly higher levels of suppression, while CPP patients with endometriosis would report higher levels of repression. We also predicted that both CPP groups would report higher levels of abuse when compared with controls and that repression and suppression will be related to reports of abuse and pain intensity.
110
E. Thomas et al. / Journal of Psychosomatic Research 60 (2006) 109 – 112
Method Participants Ninety-eight female participants completed questionnaires for the study: 37 with endometriosis-related CPP, 24 with CPP without endometriosis, and 37 nonpain controls. The response rate for the CPP patients was 92%, with five patients declining to participate. CPP patients were recruited through a Pelvic Pain clinic after they had been diagnosed through laparoscopic investigation by one of two consultant gynaecologists as having either endometriosis, or CPP without endometriosis if there was little or no evidence of pathology to attribute to their pain condition. Non-pain controls were recruited from the community if they matched the demographic profile of the CPP groups and had no evidence of a current chronic illness or chronic pain. Table 1 shows that the groups were well matched for age, ethnicity, and marital status. There was no significant difference in the length of pain experienced between the two CPP groups. After providing informed consent, participants were given a coded questionnaire to maintain anonymity. The questionnaire was either filled in at the hospital or taken away and posted back to the researcher.
Marlowe-Crowne Scale of Social Desirability [23], which measures behaviour as a defence against social threat, and the Bendig short-form of the Taylor Manifest Anxiety Scale [24]. Both scales have excellent psychometric properties and have been used extensively in research on emotional repression [10,25]. Participants are classified as repressors (low anxious, high social desirability), suppressors (high anxious, high social desirability), high anxious (high anxious, low social desirability), and low anxious (low anxious, low social desirability). Thought suppression was measured using the White Bear Suppression Inventory [26]. This scale has good concurrent validity and measures conscious effort to avoid distressing, unwanted thoughts by focusing attention elsewhere [26]. The tendency to suppress angry feelings was measured using anger held in, a subscale of the State-Trait Anger Expression Inventory [27]. These items have been used as a valid measure of anger expression in chronic pain studies [27]. Retrospective reports of abuse were measured using the Sexual and Physical Abuse History Questionnaire [28]. This quantifies the types of sexual abuse and the frequency of physical abuse experienced in both childhood and adulthood. The questionnaire has been used as a valid measure in other pain populations [28,29].
Measures
Results
Pain was measured through a composite score of two visual analogues, which measured pain at the time of reporting and cyclic pain [20], and the four-item National Women’s Sexual Pain Scale, which measured pain associated with sexual arousal and intercourse. Visual analogues are valid and reliable measures of pain [21,22], and the National Women’s Sexual Pain Scale has good internal reliability. Emotional coping styles were measured in three different ways. Repression and associated categories were determined by the method of Weinberger et al. [11] of dividing individuals into groups based on median splits on the
Between-group differences on emotional coping styles The means, percentages, and inferential statistics used to compare the three participant groups across the emotional coping styles are listed in Table 2. A significant difference was found on all the coping styles. Chi square was used to compare the three groups across the four the Weinberger repression categories (see Table 2). Post hoc pairwise analyses showed that repression was significantly more prevalent in the endometriosis CPP group than in the other two groups. Suppression was more likely to be used by both the CPP groups than the control group.
Table 1 Demographic characteristics of the participant groups Variable Age Mean (S.D.) Ethnicity (%) Caucasian Maori Pacific Island Asian Marital status (%) Single Married/defacto Separated/divorced Years of CPP Mean (S.D.)
Endometriosis related CPP
CPP without endometriosis
Non-pain controls
Statistic
Probability
30.9 (8.6)
31.7 (6.2)
32.9 (8.7)
F(2,92) = 0.50
P =.601
81 6 6 6
81 14 5 0
86 6 3 5
v 2(6) = 4.59
P =.598
47 47 6
38 54 8
49 43 5
v 2(2) = 0.886
P =.927
8.65 (5.6)
6.12 (5.8)
na
t = 1.67
P = .100
E. Thomas et al. / Journal of Psychosomatic Research 60 (2006) 109–112 Table 2 Emotional coping styles and abuse history across participant groups Variable Coping styles Weinberger et al. categories (%) Repressors (%) Suppressors (%) High anxious (%) Low anxious (%) Thought suppression M (S.D.)
Endometriosis CPP without Non-pain related CPP endometriosis controls Statistic
v 2=24.68TTT
37.1 34.3 22.9
13.6 50.0 22.7
21.6 8.2 32.4
5.7
13.6
37.8
40.50 (17.70)
45.13 (23.28)
26.05 (14.54)
F=9.36TT
15.91 (3.97)
17.43 (3.98)
14.44 (3.06)
F=5.20T
Abuse history Lifetime sexual abuse Mean rank 51.18 Lifetime physical abuse Mean rank 46.38
63.44
34.14
v 2=17.65TT
64.02
38.69
v 2=13.37TT
Anger held in M (S.D.)
111
comparisons using Mann–Whitney U, with P=.017, showed that there were no significant differences between the two CPP groups on either form of sexual abuse. The CPP patients without endometriosis had significantly higher levels of both physical and sexual abuse when compared with nonpain controls, but the endometriosis group only differed from the controls on a history of sexual abuse. Relationships between emotional coping styles, abuse history, and pain
T Pb.01. TT Pb.005. TTT Pb.001.
Control participants were significantly more likely to fall into the low anxious/low social desirability group. ANOVA with post hoc Dunnett’s C tests were used to compare groups on thought suppression and anger held in. Both CPP groups used significantly more thought suppression than did the control group. CPP patients without endometriosis also reported higher levels of holding anger-in. Abuse history Reports of abuse histories across groups were compared using nonparametric Kruskal–Wallis tests. Table 2 shows that there were significant differences between the groups on both sexual and physical abuse. Post hoc pairwise
The next objective was to investigate whether emotional coping styles were associated with a history of abuse and pain. Comparisons of abuse across the Weinberger repression categories were made using Kruskal–Wallis, while pain was compared using ANOVA (see Table 3). Post hoc tests controlling for multiple comparisons showed that the suppressors were significantly more likely to report a history of physical abuse compared with the repressors and also reported more pain than did the other three groups. There were no differences between the other groups on levels of pain. Spearman’s rho and Pearson’s correlation coefficients were used to investigate the relationships between the self-report coping measures and abuse and pain. Thought suppression was related to physical (r s=.35, Pb.01) and sexual abuse (r s=.35 Pb.01), as was anger held in (r s=.26, P b.05 for physical abuse and r s=.37, P b.01 for sexual abuse). Both thought suppression (r=.41, Pb.01) and anger held-in (r=29, Pb.01).
Discussion The results support previous findings of an association between CPP and abuse [4–8]. This study is the first to suggest that CPP patients with and without endometriosis have a tendency to use ways of coping with past trauma and emotions such as suppression, which are thought to be maladaptive in the long term. Certain limitations of the study should be noted. The number of patients in each of the groups was relatively small. Abuse was measured using a self-report scale that has
Table 3 Comparisons of pain levels and abuse history across Weinberger and colleagues’ categories of repression Variable Pain Mean (S.D.) Lifetime sexual abuse Mean rank Lifetime physical abuse Mean rank T Pb.05. TT Pb.005.
Repressors (n=22)
Suppressors (n=25)
High anxious (n=25)
Low anxious (n=19)
Statistic
9.96 (6.63)
16.81 (5.8)
9.56 (8.44)
6.03 (4.88)
F(3,87) =10.41TT
44.00
53.54
47.13
36.17
v 2(3) =5.04
35.59
56.58
49.56
39.28
v 2(3) =10.21T
112
E. Thomas et al. / Journal of Psychosomatic Research 60 (2006) 109 – 112
been linked to an underreporting of abuse [30], and the study was cross-sectional so the direction of the relationships between the variables cannot be established. Despite these limitations, most of the study’s hypotheses were supported. CPP patients without endometriosis showed a pattern similar to patients with other unexplained medical syndromes [17,18]. They had a tendency to suppress unwanted thoughts and emotions, including anger. Results for endometriosis patients were more mixed. Patients tended to be either repressors or suppressors of emotions, suggesting that this may be a more psychologically heterogeneous group. Holding in negative emotions and avoiding intrusive thoughts were related to pain intensity and a lifetime history of abuse. However, repression was not. It may be that repressors underreport pain and/or repress memories of abuse. More work is needed to understand the relationship between repression, physiological arousal, and endometriosis and how repressors cope with pain and a past history of negative events. This study has clinical implications for patients with CPP. From a psychological point of view, there appeared to be more similarities than differences between patients with a recognised medical diagnosis of CPP and those with an unexplained syndrome. Helping these patients express negative thoughts and emotions, particularly those related to past abuse may reduce pain experiences. It may be more difficult to identify the repressors, as they may deny experiencing negative feelings or past events. Future research should focus on identifying this group in a clinical context. Research should also include other chronic nonpelvic pain groups as controls to ascertain whether the findings are unique to CPP. References [1] Sand PK. Chronic pain syndromes of gynecologic origin. J Reprod Med 2004;49(3 Suppl):230 – 40. [2] Davis CJ, McMillan L. Pain in endometriosis: effectiveness of medical and surgical management. Curr Opin Obstet Gynecol 2003;15:507 – 12. [3] McGowan LPA, Clark-Carter DD, Pitts MK. Chronic pelvic pain: a meta-analytic review. Psychol Health 1998;13:937 – 51. [4] Heim C, Ehlert U, Hanker JP, Hellhammer DH. Abuse-related posttraumatic stress disorder and alterations of the hypothalamic– pituitary–adrenal axis in women with chronic pelvic pain. Psychosom Med 1998;60:309 – 18. [5] Walker EA, Katon WJ, Hansom J, Harrop-Griffiths J, Holm L, Jones ML, et al. Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain. Psychosomatics 1995;36:531 – 40. [6] Peters A, Van Dorst E, Jellis B, Van Zuuren E, Hermans J, Trimbos JB. A randomized clinical trial to compare two different approaches in women with chronic pelvic pain. Obstet Gynecol 1991;77:740 – 4. [7] Rapkin AJ, Kames LD, Darke LL, Stampler FM, Naliboff BD. History of physical and sexual abuse in women with chronic pelvic pain. Obstet Gynecol 1990;76:92 – 6. [8] Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gynecol 1990;33:130 – 6.
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