- Email: [email protected]
Dissociation, Somatization, Substance Abuse, and Coping in Women With Chronic Pelvic Pain
Dissociation, Somatization, Substance Abuse, and Coping in Women With Chronic Pelvic Pain AMY S. BADURA, ROBERT C. REITER, MD, ELIZABETH M. ALTMAIER, PhD, ANN RHOMBERG, RNC, AND DIANE ELAS, RN Objective: To examine the relationships between histories of sexual or physical abuse and current reports of dissociation, somatization, substance abuse, adaptive coping, and maladaptive coping strategies among chronic pelvic pain patients. Methods: Using a structured interview, we assessed sexual and physical abuse and somatization. The Dissociative Experiences Scale was used to assess dissociation, and an abbreviated version of the COPE scale was employed to assess adaptive and maladaptive coping strategies as well as substance abuse. Participants included 46 women with chronic pelvic pain. Results: Women with self-reported sexual or physical abuse histories were found to have significantly higher dissociation, somatization, and substance abuse scores than women without such a history. Significant positive correlations were found between reports of both dissociation and somatization with maladaptive coping strategies and among dissociation, somatization, and substance abuse. Conclusion: These results support the association between a positive abuse history and the high levels of dissociation, somatization, and substance abuse often noted in the chronic pelvic pain population. Findings suggest that such psychological variables are more likely to be associated with abuse than with the general medical condition. These psychological variables are conceptualized as maladaptive coping, which may be addressed as part of a biopsychosocial model of treatment for chronic pelvic pain patients. (Obstet Gynecol 1997;90:405–10. © 1997 by The American College of Obstetricians and Gynecologists.)
Chronic pelvic pain may be defined as noncyclic abdominal and pelvic pain of at least 6 months’ duration.1 Some medically observable pathology may exist, but the pain experienced is in excess of what would be expected normally. Often, no identifiable medical conFrom the Division of Psychological and Quantitative Foundations, The University of Iowa, Iowa City, Iowa, and the Department of Obstetrics and Gynecology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa.
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dition exists. Chronic pelvic pain is listed as the reason for approximately 10% of outpatient gynecologic consultations, one-third of laparoscopies,1 and 12–16% of the hysterectomies performed in the United States, accounting for approximately 80,000 procedures annually.2 Regrettably, hysterectomies in this population lead to reported cure rates ranging from less than 50%1 to 62% after surgery for those women with no abnormal physical findings.3 Although hundreds of anecdotal and observational reports have attempted to ascribe chronic pelvic pain to specific organic, medically rectifiable causes, no simple taxonomy has been discovered.2 Therefore, a number of researchers have turned to examining the psychological characteristics of this population and have found high prevalence rates of psychological disturbance in chronic pelvic pain patients. Women with chronic pelvic pain have been found to be more depressed, anxious, neurotic,4,5 and dissociative than control groups6 and report more histories of substance abuse and adult sexual dysfunction than controls.7 The specific psychiatric diagnoses of major depressive disorder, somatoform disorders, borderline personality disorder, and posttraumatic stress disorder have been found to occur more frequently in the chronic pelvic pain population than in the general population.4,8 –10 One of the important variables influencing these psychological difficulties may be that women with chronic pelvic pain report high rates of sexual or physical abuse in childhood or in adulthood. Given the nature of chronic pelvic pain, sexual abuse has been proposed as an especially logical etiologic component. Much higher rates of sexual abuse in both childhood and adulthood were found for chronic pelvic pain patients than for control groups.7,11,12 Although sexual abuse had been proposed as explicitly related to chronic pelvic pain, an important study13 suggested that sexual abuse alone is not predictive of chronic pelvic pain, but rather, the experience of abuse in general may promote
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the chronicity of painful conditions.13 Recently, additional data have supported the view that a history of any sort of traumatic abuse, either physical or sexual, is likely to predispose women to chronic pelvic pain.14 More specifically, sexual abuse may be associated directly with chronic pelvic pain, and physical abuse may be responsible for a more global association with chronic pain.11,12 There were two main purposes to this study within the chronic pelvic pain population. First, given the data supporting the importance of both sexual and physical abuse in chronic pelvic pain, we investigated the relationship of sexual or physical abuse history with dissociation, somatization, and substance abuse and predicted higher rates of these variables for the abused group compared with the nonabused group. Second, we examined the correlations among the psychological variables of dissociation, somatization, and substance abuse with adaptive and maladaptive coping styles, hypothesizing that each of the variables would be associated more with maladaptive coping and less with adaptive coping.
Materials and Methods Participants included 46 patients recruited from 1 calendar year of consecutive referrals to the multidisciplinary Chronic Pelvic Pain Clinic in the Department of Obstetrics and Gynecology at the University of Iowa. The recruitment period ran from May 1995 through April 1996. The participants ranged in age from 18 to 47 years, signed an informed consent form, and completed the study protocol. All participants met the selection criteria for admission to the clinic, which consisted of experiencing noncyclic pelvic pain of longer than 6 months’ duration and having a negative laparoscopy. Sexual and physical abuse were assessed using a structured interview given as part of the typical intake procedure for new patients at the Chronic Pelvic Pain Clinic. Each interview lasted approximately 30 minutes and was conducted face to face in a private room by a female registered nurse clinician. The sexual abuse portion of the interview specifically assessed the areas of genital injury, rape, and molestation or incest. If abuse was present, the following information was solicited: age(s) at the time of abuse, relationship to the perpetrator(s), circumstances of the abuse, and subsequent treatment. Physical abuse was assessed as part of the social and family history section of the structured intake interview. Patients were asked whether or not they had a history of childhood or adult physical abuse, and if abuse was reported, the specific age(s) and circumstances surrounding the abuse were queried. Sexual abuse was defined as any coerced sexual expe-
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rience involving actual physical contact (eg, penetration, fondling, forced touching of another’s genitals), and physical abuse was defined as a purposeful act upon the participant resulting in objective tissue damage lasting at least 24 hours (eg, bruises, cuts, broken bones). Dissociation was assessed using the Dissociative Experiences Scale,15,16 which is a 28-item, self-report questionnaire designed to assess dissociative experiences, including disturbance in memory, identity, awareness, and cognition not occurring under the influence of alcohol or drugs. The possible response options increase in increments of 10% and range from 0% (this never happens) to 100% (this always happens). The participant was asked to circle the corresponding percentage of time she has had the particular experience described in each item. The Dissociative Experiences Scale has been found to be a reliable and valid instrument with good test-retest (.84) and internal consistency reliability coefficients (generally .90 or greater) and demonstrable construct validity.16 The internal consistency reliability coefficient for this sample was .94. Somatization was assessed in this study using the systems review section of the structured intake interview previously described. Each patient was asked to indicate all of a list of 45 symptoms for which she had been seen by a doctor or that altered her normal life pattern. Four categories of symptoms were assessed, including general, gastroenterologic, urologic, and neurologic complaints. Gynecologic symptoms were not assessed due to the nature of the presenting problem of chronic pelvic pain, which would confound this area of somatization. The total number of items endorsed was used to assess the overall severity of somatization. This somatization measure has been validated against the Structured Clinical Interview for the DSM-III-R17 for somatization disorder, somatoform pain disorder, undifferentiated somatoform disorder, and hypochondriasis. Reiter (unpublished manuscript) reported that convergent validity for the somatization measure with the structured interview was good at R 5 .56 (P , .00001). Internal consistency reliability for this sample was supported with a coefficient a of .84. Substance abuse, adaptive coping strategies, and maladaptive coping strategies were assessed using items from the COPE18 scale, which is a self-report measure designed to assess the different ways that people respond to stress. The patient was asked to mark the response option, which ranged from 1 (I have not been doing this at all) to 4 (I have been doing this a lot), that best represented how often she had used a specific coping behavior. The COPE items selected for use in this study were discussed originally18 as assessing either adaptive or maladaptive coping styles. These
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groupings were based on clustering determined by correlations among the original COPE subscales.18 Carver developed an abbreviated version of the COPE that consists of the items with the highest factor loadings from each of the original subscales (personal communication). The abbreviated form of the COPE was used in this study, and items were divided into adaptive and maladaptive measures based on the previously reported clusters. These new measures of adaptive and maladaptive coping were analyzed, and those items with internal consistency reliabilities significant at the P , .01 level were selected for use in the present study. This resulted in a total of eight adaptive items and eight maladaptive items. The two items addressing substance and alcohol abuse were also retained. The final adaptive coping measure used in this study assessed behaviors associated with positive resolution seeking, including active coping, use of emotional support, positive reframing, and planning. The scale had an internal consistency reliability coefficient of .84. Our maladaptive coping measure examined behaviors representative of a more avoidant coping style, including self-distraction, denial, behavioral disengagement, and venting. The internal consistency coefficient for the maladaptive scale was .70. Statistical procedures consisted of nonparametric analyses due to the use of ordinal scales and sample size. Mann-Whitney U tests were used to compare the abused and nonabused groups on levels of dissociation, somatization, and substance abuse. Spearman coefficients of rank correlation were calculated to examine the relationships among dissociation, somatization, and substance abuse and maladaptive and adaptive coping strategies. Because we had clear a priori hypotheses about the directionality of the anticipated results, onetailed tests were conducted.
Results The women in this sample ranged in age from 18 to 47 years, with a mean age of 30.98 years and a standard deviation of 7.11. Examination of the marital status of the women in the total sample revealed that 32.6% (15) were single, 50.0% (23) were married, and 17.4% (eight) were divorced. The participants were divided into abused and nonabused groups based on their responses to the sexual and physical abuse interview questions. A t test revealed that the mean ages of the abused (32.11 years) and nonabused groups (29.37 years) were not significantly different. The abused group consisted of those women reporting sexual or physical abuse during the course of a lifetime, including those experiencing abuse as children (age 17 years or younger) or as adults (age
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Table 1. Group Comparisons
Dissociation Mean rank Somatization Mean rank Substance abuse Mean rank Maladaptive coping Mean rank Adaptive coping Mean rank
Abused
Nonabused
28.26
16.74
26.61
19.08
25.81
20.21
24.46
22.13
23.35
23.71
P value .0021* .0299† .0310† .2803 .4944
* P , .01. P , .05. All comparisons were hypothesis-driven, one-tailed Mann-Whitney U tests. †
18 years or older). Abuse during the course of a lifetime was reported by 59% (27) of the women in this sample compared with 41% (19) not reporting an abuse history. Mann-Whitney U tests revealed that the group reporting abuse had significantly higher dissociation, somatization, and substance abuse scores than the nonabused group. Analyses did not find significant differences between the abused and nonabused groups for maladaptive or adaptive coping (P . .05) (Table 1). The correlations among dissociation, somatization, substance abuse, maladaptive coping, and adaptive coping were calculated using Spearman coefficients of rank correlation. Significant positive correlations were found between dissociation and each of the following variables: somatization, substance abuse, and maladaptive coping. Significant positive correlations were also found between somatization and substance abuse as well as between somatization and maladaptive coping (Table 2). The power to detect moderate correlations in the range of .30 to .50 at the .05 level for a sample size of 46 is .95.19
Discussion The prevalence rates of abuse found in this study are consistent with previously published prevalence rates for chronic pelvic pain samples. For example, one study with careful abuse assessment found that 56% of their chronic pelvic pain sample reported a lifetime history of sexual abuse, and 50% of their chronic pelvic pain sample reported a lifetime history of physical abuse.12 For comparison, that study also examined headache and pain-free groups on abuse history. Any lifetime sexual abuse was reported by 43% of the headache group and by 28% of the pain-free group. Lifetime physical abuse was reported by 38% of the headache group and by 30% of the pain-free comparison group.12 A large body of literature exists documenting the
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Table 2. Spearman Coefficients of Rank Correlation
1 2 3 4 5
1
2
3
4
5
1.00 .43* .47† .44† 2.22
1.00 .44* .37* 2.11
1.00 .18 .02
1.00 2.09
1.00
1 5 Dissociative experiences scale; 2 5 somatization; 3 5 substance abuse; 4 5 maladaptive coping; 5 5 adaptive coping. * Significant at .05. † Significant at .01.
relationship between abuse and lasting psychological distress. Women reporting histories of abuse have been found to be at increased risk for a long list of psychiatric disturbances, including posttraumatic stress disorder, dissociative identity disorder, borderline personality disorder, somatization disorders, and substance abuse.8,20,21 Based on the strong trend of dissociative phenomena in these disorders as well as the direct links to somatization and substance abuse, we focused on these variables as the sequelae of abuse to be addressed in the present study. Dissociation is a disruption in the usually integrated function of consciousness, memory, identity, or perception of the environment.22 An early explanation of dissociation was offered by Pierre Janet, who posited that frightening experiences may not fit into existing cognitive schemes, and memories of these frightening experiences can be split off from consciousness.23 Sexual and physical abuse are well within the realm of frightening experiences, and as a result, the victim may attempt to separate the abuse from conscious awareness.24 The psychological distance afforded by this defense makes dissociation an adaptive coping skill in the face of traumatic events, allowing the victim to escape what is, in reality, inescapable.25 People who use dissociation to deal with trauma are developing and employing normal coping skills,26 but dissociation becomes maladaptive if it continues throughout the victims’ lives after the trauma has passed. Examples of such maladaptive outcomes include, but are not limited to, detachment, numbness, denial, loss of memories, guilt, shame, and self-destructive behaviors.24 Women with chronic pelvic pain have been found to have significantly higher scores on the Dissociative Experiences Scale than a comparison group without pain.7 This study also compared those women with histories of severe sexual abuse with those without histories of abuse and found significantly higher rates of dissociation in the abused group. Supporting the importance of sexual and physical abuse in dissociation, Dissociative Experiences Scale scores have been found to be highest among psychiatric patients experiencing
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both sexual and physical abuse, followed by patients with either sexual or physical abuse, and were lowest for patients reporting no abuse.27 Our findings are consistent with previous work indicating higher levels of dissociation in an abused group than in a nonabused group. The average normative Dissociative Experiences Scale score for a member of the general adult population has been reported as ranging from 3.7 to 7.8.16 Our findings for the nonabused group fell well within this normal range, with a mean score of 5.1. Supporting the specific link between abuse and dissociation, the mean for our abused group indicated significantly more pathology, with a mean score at 15.1. Somatization is the presence of physical symptoms that suggest a medical condition and cause clinically significant distress or impairment but that are not fully accounted for by a general medical condition, the effects of a substance, or another mental disorder.22 Reiter and Milburn28 compared an age-matched, pain-free control group with a chronic pelvic pain group and found that the chronic pelvic pain group had nearly five times as many nongynecologic surgeries and had sought treatment for four times as many unrelated medical complaints. High rates of medical attention seeking apparently unrelated to chronic pelvic pain suggest that women with chronic pelvic pain may “convert” psychological difficulties into physical symptoms and favor a somatic over a psychological representation of distress. By converting their issues, problems are not dealt with directly, and somatization becomes an avoidant coping strategy. A study examining women with possible somatic causes of chronic pelvic pain compared with women without identifiable somatic abnormality concluded that a history of sexual abuse is a significant predisposing risk for somatization and nonsomatic chronic pelvic pain.29 However, consistent with the trend in the literature toward the importance of both sexual and physical abuse in chronic pelvic pain, recent work has challenged the notion of a specific relationship between sexual abuse and somatization, finding instead that childhood physical abuse was associated more strongly with later somatization, depression, and anxiety.30 Thus, both sexual and physical abuse have been shown to have important links to somatization. The results of our study provide additional evidence supporting somatization as a sequelae of a history of sexual or physical abuse in chronic pelvic pain patients. Total somatization scores were significantly higher for the abused group (mean 5 11.70) compared with the nonabused group (mean 5 8.68). Given the finding that a discriminatory score of 13 correctly distinguished approximately 70% of women with a pain-related psy-
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chological diagnosis from those without such a diagnosis (Reiter, unpublished manuscript), the mean somatization score of nearly 12 for the abused group has obvious clinical significance. A clear relationship has also been found between childhood sexual abuse and later alcohol and substance abuse.31,32 One study found that sexually abused, female, crisis center clients had ten times the likelihood of a substance abuse history and two times the likelihood of alcoholism compared with a group of nonabused female clients.33 Drug or alcohol abuse may serve as a form of chemically induced dissociation, or avoidance, which allows an abused women to separate from her environment and emotional distress.21 Despite our limited assessment of substance abuse as a coping strategy, our results show significantly greater self-reported turning to alcohol and drugs to cope in the abused group than in the nonabused group. The results of this study provide solid evidence for dissociation, somatization, and substance abuse as sequelae of abuse. Chronic pain populations have been found to experience more frequent and more severe stressful life events than the general public (ie, abuse), and it is thought that such stressful life events undermine the personal coping strategies of the individual and result in avoidance-based coping responses.34 The use of problem-focused coping skills has been shown to be associated positively with higher self-efficacy35; however, survivors of abuse often have low self-esteem, self-efficacy, and self-worth.21,36 Indeed, the psychological variables included in this study and shown to be associated significantly with abuse may be conceptualized as pervasive, avoidancebased, coping responses. The positive correlational findings in this chronic pelvic pain sample reveal a logical pattern of dissociation and somatization with maladaptive, avoidance-based coping. Separating one’s self from normal, conscious awareness and converting psychological distress into physical symptoms are powerful coping strategies; unfortunately, their use may preclude or inhibit the development of more solutionfocused, adaptive coping skills. Although the correlations in this study examining substance abuse and coping do not reach statistical significance, substance abuse commonly is accepted as a maladaptive coping strategy. In addition, the significant positive correlations among dissociation, somatization, and substance abuse suggest a logical clustering of maladaptive tendencies, with higher levels of one form of psychopathology associated with higher levels of each of the others. Also important in positioning dissociation, somatization, and substance abuse as less effective coping strategies is the finding that none of these
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psychological variables correlated significantly with our measure of adaptive coping. The major conclusion that may be drawn from this body of data is that the abuse experience seems to be one, albeit significant, etiologic factor in dissociation, somatization, and substance abuse for women with chronic pelvic pain. Therefore, given the higher risk for psychopathology in abused chronic pelvic pain patients, psychological interventions may be especially important for that subset of women. We draw attention to many of the psychological variables previously associated with chronic pelvic pain in the literature, and we suggest that these variables may be linked specifically to the high rates of abuse in this population rather than to the medical condition itself. The findings of the present study call for the further examination of psychological variables with respect to abuse history. The first limitation of the present study is the failure to include pain-free and other chronic pain control groups. Second, this study was cross sectional in nature, limiting our ability to determine conclusively whether psychological symptomotology predated or postdated the abuse. However, because abuse cannot be manipulated experimentally, cause-and-effect conclusions about this variable are not possible, and correlational findings, such as those reported here, provide the strongest evidence available for studying sequelae of abuse. Longitudinal outcome research examining changes in psychological variables over the course of multidisciplinary treatment is perhaps the most important future directive. The results of this study clearly position dissociation, somatization, and substance abuse as maladaptive coping strategies that may be amenable to psychological intervention. The interplay between the medical condition of chronic pelvic pain, the environmental experience of abuse, and the psychological variables examined in this study exemplify the importance of working from a biopsychosocial model with this population. Multidisciplinary treatment teams, which include medical, educational, and psychological interventions, have been supported in the literature as viable alternatives in the treatment of chronic pelvic pain.2,8 Our conceptualization of many psychological sequelae of abuse as maladaptive coping strategies emphasizes the value of multimodal treatment that includes a focus on developing more adaptive ways of coping, especially for the abused subset of this patient population.
References 1. Reiter RC, Gambone JC. Demographic and historic variables in women with idiopathic chronic pelvic pain. Obstet Gynecol 1990; 75:428 –32.
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2. Milburn A, Reiter RC, Rhomberg A. Multidisciplinary approach to chronic pelvic pain. Obstet Gynecol Clin North Am 1993;20:643– 61. 3. Hillis SD, Marchbanks PA, Peterson HB. The effectiveness of hysterectomy for chronic pelvic pain. Obstet Gynecol 1995;86: 941–5. 4. Harrop-Griffiths J, Katon W, Walker E, Holm L, Russo J, Hickok L. The association between chronic pelvic pain, psychiatric diagnoses, and childhood sexual abuse. Obstet Gynecol 1988;71:589 – 94. 5. Fry RP, Crisp AH, Beard RW, McGuigan S. Psychosocial aspects of chronic pelvic pain, with special reference to sexual abuse: A study of 164 women. Postgrad Med J 1993;69:566 –74. 6. Walker E, Katon W, Harrop-Griffiths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatr 1988;145:75– 80. 7. Walker EA, Katon WJ, Neraas K, Jemelka RP, Massoth D. Dissociation in women with chronic pelvic pain. Am J Psychiatr 1992; 149:534 –7. 8. Wood DP, Wiesner MG, Reiter RC. Psychological chronic pelvic pain: Diagnosis and management. Clin Obstet Gynecol 1990;33: 179 –95. 9. Benedikt RA, Kolb LC. Preliminary findings on chronic pain and post-traumatic stress disorder. Am J Psychiatr 1986;143:908 –10. 10. Muse M. Stress-related, post-traumatic chronic pain syndrome: Criteria for diagnosis, and preliminary report on prevalence. Pain 1985;23:295–300. 11. Walker EA, Stenchever MA. Sexual victimization and chronic pelvic pain. Obstet Gynecol Clin North Am 1993;20:795– 807. 12. Walling MK, Reiter RC, O’Hara MW, Milburn A, Lilly G, Vincent SD. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994;84:193–9. 13. 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. 14. Toomey TC, Hernandez JT, Gittelman DF, Hulka JF. Relationship of sexual and physical abuse to pain and psychological assessment variables in chronic pelvic pain patients. Pain 1993;53:105–9. 15. Bernstein EM, Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 1986;174:727–35. 16. Bernstein EM, Putnam EM. An update on the Dissociative Experiences Scale. Dissoc: Progr Dissoc Dis 1993;6:16 –27. 17. Spitzer RL, Williams JBW, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R Patient Edition (SCID-P). Washington, DC: American Psychiatric Association, 1990. 18. Carver CS, Scheier MF, Weintraub JK. Assessing coping strategies: A theoretically based approach. J Pers Soc Psychol 1989;56:267– 83. 19. Cohen J. Statistical power analysis for behavioral sciences. Rev. ed. New York: Academic Press, 1977. 20. Walker EA, Katon WJ, Hansom J, Harrop-Griffiths J, Holm L, Jones ML, et al. Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med 1992;54:658 – 64. 21. Briere J, Runtz M. Childhood sexual abuse: Long-term sequelae and implications for psychological assessment. J Interpers Violence 1993;8:312–30. 22. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed (DSM-IV). Washington, DC: American Psychiatric Association, 1994.
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23. van der Kolk BA, van der Hart O. Pierre Janet and the breakdown of adaptation of psychological trauma. Am J Psychiatr 1989;146: 1530 – 40. 24. Silon B. Dissociation: A symptom of incest. Individ Psychol 1992;48:155– 64. 25. Waites EA. Trauma and survival: Post-traumatic and dissociative disorders in women. New York: Norton, 1993. 26. Foy DW, ed. Treating PTSD: Cognitive behavioral strategies. New York: Guilford, 1992. 27. Chu JA, Dill DL. Dissociative symptoms in relation to childhood physical and sexual abuse. Am J Psychiatr 1990;147:887–92. 28. Reiter RC, Milburn A. Management of chronic pelvic pain. Postgrad Obstet Gynecol 1992;12:1–7. 29. Reiter RC, Shakerin LR, Gambone JC, Milburn AK. Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain. Am J Obstet Gynecol 1991; 165:104 –9. 30. Walling MK, O’Hara MW, Reiter RC, Milburn A, Lilly G, Vincent SD. Abuse history and chronic pain in women: II. A multivariate analysis of abuse and psychological morbidity. Obstet Gynecol 1994;84:200 – 6. 31. Singer MI, Petchers MK, Hussey D. The relationship between sexual abuse and substance abuse among psychiatrically hospitalized adolescents. Child Abuse Negl 1989;13:319 –25. 32. Dembo R, Williams L, LaVoie L, Berry E, Getreu A, Wish EL, et al. Physical abuse, sexual victimization, and drug use: Replication of a structural analysis among a new sample of high risk youths. Violence Victims 1989;4:121–38. 33. Biere J, Runtz M. Post sexual abuse trauma: Data and implications for clinical practice. J Interpersonal Violence 1987;2:367–79. 34. Lethem J, Slade PD, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception-I. Behav Res Ther 1983;21: 401– 8. 35. Chwalisz K, Altmaier EM, Russell DW. Causal attributions, selfefficacy cognitions, and coping with stress. J Soc Clin Psychol 1992;11:377– 400. 36. McCann IL, Sakheim DK, Abrahamson DJ. Trauma and victimization: A model of psychological adaptation. Counseling Psychol 1988;16:531–94.
Address reprint requests to:
Robert C. Reiter, MD Department of Obstetrics and Gynecology University of Iowa Hospitals and Clinics 200 Hawkins Drive, Room C505 GH Iowa City, IA 52242-1009 E-mail: [email protected]
Received December 16, 1996. Received in revised form April 28, 1997. Accepted May 2, 1997. Copyright © 1997 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology
Chronic pelvic pain may be defined as noncyclic abdominal and pelvic pain of at least 6 months’ duration.1 Some medically observable pathology may exist, but the pain experienced is in excess of what would be expected normally. Often, no identifiable medical conFrom the Division of Psychological and Quantitative Foundations, The University of Iowa, Iowa City, Iowa, and the Department of Obstetrics and Gynecology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa.
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dition exists. Chronic pelvic pain is listed as the reason for approximately 10% of outpatient gynecologic consultations, one-third of laparoscopies,1 and 12–16% of the hysterectomies performed in the United States, accounting for approximately 80,000 procedures annually.2 Regrettably, hysterectomies in this population lead to reported cure rates ranging from less than 50%1 to 62% after surgery for those women with no abnormal physical findings.3 Although hundreds of anecdotal and observational reports have attempted to ascribe chronic pelvic pain to specific organic, medically rectifiable causes, no simple taxonomy has been discovered.2 Therefore, a number of researchers have turned to examining the psychological characteristics of this population and have found high prevalence rates of psychological disturbance in chronic pelvic pain patients. Women with chronic pelvic pain have been found to be more depressed, anxious, neurotic,4,5 and dissociative than control groups6 and report more histories of substance abuse and adult sexual dysfunction than controls.7 The specific psychiatric diagnoses of major depressive disorder, somatoform disorders, borderline personality disorder, and posttraumatic stress disorder have been found to occur more frequently in the chronic pelvic pain population than in the general population.4,8 –10 One of the important variables influencing these psychological difficulties may be that women with chronic pelvic pain report high rates of sexual or physical abuse in childhood or in adulthood. Given the nature of chronic pelvic pain, sexual abuse has been proposed as an especially logical etiologic component. Much higher rates of sexual abuse in both childhood and adulthood were found for chronic pelvic pain patients than for control groups.7,11,12 Although sexual abuse had been proposed as explicitly related to chronic pelvic pain, an important study13 suggested that sexual abuse alone is not predictive of chronic pelvic pain, but rather, the experience of abuse in general may promote
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the chronicity of painful conditions.13 Recently, additional data have supported the view that a history of any sort of traumatic abuse, either physical or sexual, is likely to predispose women to chronic pelvic pain.14 More specifically, sexual abuse may be associated directly with chronic pelvic pain, and physical abuse may be responsible for a more global association with chronic pain.11,12 There were two main purposes to this study within the chronic pelvic pain population. First, given the data supporting the importance of both sexual and physical abuse in chronic pelvic pain, we investigated the relationship of sexual or physical abuse history with dissociation, somatization, and substance abuse and predicted higher rates of these variables for the abused group compared with the nonabused group. Second, we examined the correlations among the psychological variables of dissociation, somatization, and substance abuse with adaptive and maladaptive coping styles, hypothesizing that each of the variables would be associated more with maladaptive coping and less with adaptive coping.
Materials and Methods Participants included 46 patients recruited from 1 calendar year of consecutive referrals to the multidisciplinary Chronic Pelvic Pain Clinic in the Department of Obstetrics and Gynecology at the University of Iowa. The recruitment period ran from May 1995 through April 1996. The participants ranged in age from 18 to 47 years, signed an informed consent form, and completed the study protocol. All participants met the selection criteria for admission to the clinic, which consisted of experiencing noncyclic pelvic pain of longer than 6 months’ duration and having a negative laparoscopy. Sexual and physical abuse were assessed using a structured interview given as part of the typical intake procedure for new patients at the Chronic Pelvic Pain Clinic. Each interview lasted approximately 30 minutes and was conducted face to face in a private room by a female registered nurse clinician. The sexual abuse portion of the interview specifically assessed the areas of genital injury, rape, and molestation or incest. If abuse was present, the following information was solicited: age(s) at the time of abuse, relationship to the perpetrator(s), circumstances of the abuse, and subsequent treatment. Physical abuse was assessed as part of the social and family history section of the structured intake interview. Patients were asked whether or not they had a history of childhood or adult physical abuse, and if abuse was reported, the specific age(s) and circumstances surrounding the abuse were queried. Sexual abuse was defined as any coerced sexual expe-
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rience involving actual physical contact (eg, penetration, fondling, forced touching of another’s genitals), and physical abuse was defined as a purposeful act upon the participant resulting in objective tissue damage lasting at least 24 hours (eg, bruises, cuts, broken bones). Dissociation was assessed using the Dissociative Experiences Scale,15,16 which is a 28-item, self-report questionnaire designed to assess dissociative experiences, including disturbance in memory, identity, awareness, and cognition not occurring under the influence of alcohol or drugs. The possible response options increase in increments of 10% and range from 0% (this never happens) to 100% (this always happens). The participant was asked to circle the corresponding percentage of time she has had the particular experience described in each item. The Dissociative Experiences Scale has been found to be a reliable and valid instrument with good test-retest (.84) and internal consistency reliability coefficients (generally .90 or greater) and demonstrable construct validity.16 The internal consistency reliability coefficient for this sample was .94. Somatization was assessed in this study using the systems review section of the structured intake interview previously described. Each patient was asked to indicate all of a list of 45 symptoms for which she had been seen by a doctor or that altered her normal life pattern. Four categories of symptoms were assessed, including general, gastroenterologic, urologic, and neurologic complaints. Gynecologic symptoms were not assessed due to the nature of the presenting problem of chronic pelvic pain, which would confound this area of somatization. The total number of items endorsed was used to assess the overall severity of somatization. This somatization measure has been validated against the Structured Clinical Interview for the DSM-III-R17 for somatization disorder, somatoform pain disorder, undifferentiated somatoform disorder, and hypochondriasis. Reiter (unpublished manuscript) reported that convergent validity for the somatization measure with the structured interview was good at R 5 .56 (P , .00001). Internal consistency reliability for this sample was supported with a coefficient a of .84. Substance abuse, adaptive coping strategies, and maladaptive coping strategies were assessed using items from the COPE18 scale, which is a self-report measure designed to assess the different ways that people respond to stress. The patient was asked to mark the response option, which ranged from 1 (I have not been doing this at all) to 4 (I have been doing this a lot), that best represented how often she had used a specific coping behavior. The COPE items selected for use in this study were discussed originally18 as assessing either adaptive or maladaptive coping styles. These
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groupings were based on clustering determined by correlations among the original COPE subscales.18 Carver developed an abbreviated version of the COPE that consists of the items with the highest factor loadings from each of the original subscales (personal communication). The abbreviated form of the COPE was used in this study, and items were divided into adaptive and maladaptive measures based on the previously reported clusters. These new measures of adaptive and maladaptive coping were analyzed, and those items with internal consistency reliabilities significant at the P , .01 level were selected for use in the present study. This resulted in a total of eight adaptive items and eight maladaptive items. The two items addressing substance and alcohol abuse were also retained. The final adaptive coping measure used in this study assessed behaviors associated with positive resolution seeking, including active coping, use of emotional support, positive reframing, and planning. The scale had an internal consistency reliability coefficient of .84. Our maladaptive coping measure examined behaviors representative of a more avoidant coping style, including self-distraction, denial, behavioral disengagement, and venting. The internal consistency coefficient for the maladaptive scale was .70. Statistical procedures consisted of nonparametric analyses due to the use of ordinal scales and sample size. Mann-Whitney U tests were used to compare the abused and nonabused groups on levels of dissociation, somatization, and substance abuse. Spearman coefficients of rank correlation were calculated to examine the relationships among dissociation, somatization, and substance abuse and maladaptive and adaptive coping strategies. Because we had clear a priori hypotheses about the directionality of the anticipated results, onetailed tests were conducted.
Results The women in this sample ranged in age from 18 to 47 years, with a mean age of 30.98 years and a standard deviation of 7.11. Examination of the marital status of the women in the total sample revealed that 32.6% (15) were single, 50.0% (23) were married, and 17.4% (eight) were divorced. The participants were divided into abused and nonabused groups based on their responses to the sexual and physical abuse interview questions. A t test revealed that the mean ages of the abused (32.11 years) and nonabused groups (29.37 years) were not significantly different. The abused group consisted of those women reporting sexual or physical abuse during the course of a lifetime, including those experiencing abuse as children (age 17 years or younger) or as adults (age
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Table 1. Group Comparisons
Dissociation Mean rank Somatization Mean rank Substance abuse Mean rank Maladaptive coping Mean rank Adaptive coping Mean rank
Abused
Nonabused
28.26
16.74
26.61
19.08
25.81
20.21
24.46
22.13
23.35
23.71
P value .0021* .0299† .0310† .2803 .4944
* P , .01. P , .05. All comparisons were hypothesis-driven, one-tailed Mann-Whitney U tests. †
18 years or older). Abuse during the course of a lifetime was reported by 59% (27) of the women in this sample compared with 41% (19) not reporting an abuse history. Mann-Whitney U tests revealed that the group reporting abuse had significantly higher dissociation, somatization, and substance abuse scores than the nonabused group. Analyses did not find significant differences between the abused and nonabused groups for maladaptive or adaptive coping (P . .05) (Table 1). The correlations among dissociation, somatization, substance abuse, maladaptive coping, and adaptive coping were calculated using Spearman coefficients of rank correlation. Significant positive correlations were found between dissociation and each of the following variables: somatization, substance abuse, and maladaptive coping. Significant positive correlations were also found between somatization and substance abuse as well as between somatization and maladaptive coping (Table 2). The power to detect moderate correlations in the range of .30 to .50 at the .05 level for a sample size of 46 is .95.19
Discussion The prevalence rates of abuse found in this study are consistent with previously published prevalence rates for chronic pelvic pain samples. For example, one study with careful abuse assessment found that 56% of their chronic pelvic pain sample reported a lifetime history of sexual abuse, and 50% of their chronic pelvic pain sample reported a lifetime history of physical abuse.12 For comparison, that study also examined headache and pain-free groups on abuse history. Any lifetime sexual abuse was reported by 43% of the headache group and by 28% of the pain-free group. Lifetime physical abuse was reported by 38% of the headache group and by 30% of the pain-free comparison group.12 A large body of literature exists documenting the
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Table 2. Spearman Coefficients of Rank Correlation
1 2 3 4 5
1
2
3
4
5
1.00 .43* .47† .44† 2.22
1.00 .44* .37* 2.11
1.00 .18 .02
1.00 2.09
1.00
1 5 Dissociative experiences scale; 2 5 somatization; 3 5 substance abuse; 4 5 maladaptive coping; 5 5 adaptive coping. * Significant at .05. † Significant at .01.
relationship between abuse and lasting psychological distress. Women reporting histories of abuse have been found to be at increased risk for a long list of psychiatric disturbances, including posttraumatic stress disorder, dissociative identity disorder, borderline personality disorder, somatization disorders, and substance abuse.8,20,21 Based on the strong trend of dissociative phenomena in these disorders as well as the direct links to somatization and substance abuse, we focused on these variables as the sequelae of abuse to be addressed in the present study. Dissociation is a disruption in the usually integrated function of consciousness, memory, identity, or perception of the environment.22 An early explanation of dissociation was offered by Pierre Janet, who posited that frightening experiences may not fit into existing cognitive schemes, and memories of these frightening experiences can be split off from consciousness.23 Sexual and physical abuse are well within the realm of frightening experiences, and as a result, the victim may attempt to separate the abuse from conscious awareness.24 The psychological distance afforded by this defense makes dissociation an adaptive coping skill in the face of traumatic events, allowing the victim to escape what is, in reality, inescapable.25 People who use dissociation to deal with trauma are developing and employing normal coping skills,26 but dissociation becomes maladaptive if it continues throughout the victims’ lives after the trauma has passed. Examples of such maladaptive outcomes include, but are not limited to, detachment, numbness, denial, loss of memories, guilt, shame, and self-destructive behaviors.24 Women with chronic pelvic pain have been found to have significantly higher scores on the Dissociative Experiences Scale than a comparison group without pain.7 This study also compared those women with histories of severe sexual abuse with those without histories of abuse and found significantly higher rates of dissociation in the abused group. Supporting the importance of sexual and physical abuse in dissociation, Dissociative Experiences Scale scores have been found to be highest among psychiatric patients experiencing
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both sexual and physical abuse, followed by patients with either sexual or physical abuse, and were lowest for patients reporting no abuse.27 Our findings are consistent with previous work indicating higher levels of dissociation in an abused group than in a nonabused group. The average normative Dissociative Experiences Scale score for a member of the general adult population has been reported as ranging from 3.7 to 7.8.16 Our findings for the nonabused group fell well within this normal range, with a mean score of 5.1. Supporting the specific link between abuse and dissociation, the mean for our abused group indicated significantly more pathology, with a mean score at 15.1. Somatization is the presence of physical symptoms that suggest a medical condition and cause clinically significant distress or impairment but that are not fully accounted for by a general medical condition, the effects of a substance, or another mental disorder.22 Reiter and Milburn28 compared an age-matched, pain-free control group with a chronic pelvic pain group and found that the chronic pelvic pain group had nearly five times as many nongynecologic surgeries and had sought treatment for four times as many unrelated medical complaints. High rates of medical attention seeking apparently unrelated to chronic pelvic pain suggest that women with chronic pelvic pain may “convert” psychological difficulties into physical symptoms and favor a somatic over a psychological representation of distress. By converting their issues, problems are not dealt with directly, and somatization becomes an avoidant coping strategy. A study examining women with possible somatic causes of chronic pelvic pain compared with women without identifiable somatic abnormality concluded that a history of sexual abuse is a significant predisposing risk for somatization and nonsomatic chronic pelvic pain.29 However, consistent with the trend in the literature toward the importance of both sexual and physical abuse in chronic pelvic pain, recent work has challenged the notion of a specific relationship between sexual abuse and somatization, finding instead that childhood physical abuse was associated more strongly with later somatization, depression, and anxiety.30 Thus, both sexual and physical abuse have been shown to have important links to somatization. The results of our study provide additional evidence supporting somatization as a sequelae of a history of sexual or physical abuse in chronic pelvic pain patients. Total somatization scores were significantly higher for the abused group (mean 5 11.70) compared with the nonabused group (mean 5 8.68). Given the finding that a discriminatory score of 13 correctly distinguished approximately 70% of women with a pain-related psy-
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chological diagnosis from those without such a diagnosis (Reiter, unpublished manuscript), the mean somatization score of nearly 12 for the abused group has obvious clinical significance. A clear relationship has also been found between childhood sexual abuse and later alcohol and substance abuse.31,32 One study found that sexually abused, female, crisis center clients had ten times the likelihood of a substance abuse history and two times the likelihood of alcoholism compared with a group of nonabused female clients.33 Drug or alcohol abuse may serve as a form of chemically induced dissociation, or avoidance, which allows an abused women to separate from her environment and emotional distress.21 Despite our limited assessment of substance abuse as a coping strategy, our results show significantly greater self-reported turning to alcohol and drugs to cope in the abused group than in the nonabused group. The results of this study provide solid evidence for dissociation, somatization, and substance abuse as sequelae of abuse. Chronic pain populations have been found to experience more frequent and more severe stressful life events than the general public (ie, abuse), and it is thought that such stressful life events undermine the personal coping strategies of the individual and result in avoidance-based coping responses.34 The use of problem-focused coping skills has been shown to be associated positively with higher self-efficacy35; however, survivors of abuse often have low self-esteem, self-efficacy, and self-worth.21,36 Indeed, the psychological variables included in this study and shown to be associated significantly with abuse may be conceptualized as pervasive, avoidancebased, coping responses. The positive correlational findings in this chronic pelvic pain sample reveal a logical pattern of dissociation and somatization with maladaptive, avoidance-based coping. Separating one’s self from normal, conscious awareness and converting psychological distress into physical symptoms are powerful coping strategies; unfortunately, their use may preclude or inhibit the development of more solutionfocused, adaptive coping skills. Although the correlations in this study examining substance abuse and coping do not reach statistical significance, substance abuse commonly is accepted as a maladaptive coping strategy. In addition, the significant positive correlations among dissociation, somatization, and substance abuse suggest a logical clustering of maladaptive tendencies, with higher levels of one form of psychopathology associated with higher levels of each of the others. Also important in positioning dissociation, somatization, and substance abuse as less effective coping strategies is the finding that none of these
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psychological variables correlated significantly with our measure of adaptive coping. The major conclusion that may be drawn from this body of data is that the abuse experience seems to be one, albeit significant, etiologic factor in dissociation, somatization, and substance abuse for women with chronic pelvic pain. Therefore, given the higher risk for psychopathology in abused chronic pelvic pain patients, psychological interventions may be especially important for that subset of women. We draw attention to many of the psychological variables previously associated with chronic pelvic pain in the literature, and we suggest that these variables may be linked specifically to the high rates of abuse in this population rather than to the medical condition itself. The findings of the present study call for the further examination of psychological variables with respect to abuse history. The first limitation of the present study is the failure to include pain-free and other chronic pain control groups. Second, this study was cross sectional in nature, limiting our ability to determine conclusively whether psychological symptomotology predated or postdated the abuse. However, because abuse cannot be manipulated experimentally, cause-and-effect conclusions about this variable are not possible, and correlational findings, such as those reported here, provide the strongest evidence available for studying sequelae of abuse. Longitudinal outcome research examining changes in psychological variables over the course of multidisciplinary treatment is perhaps the most important future directive. The results of this study clearly position dissociation, somatization, and substance abuse as maladaptive coping strategies that may be amenable to psychological intervention. The interplay between the medical condition of chronic pelvic pain, the environmental experience of abuse, and the psychological variables examined in this study exemplify the importance of working from a biopsychosocial model with this population. Multidisciplinary treatment teams, which include medical, educational, and psychological interventions, have been supported in the literature as viable alternatives in the treatment of chronic pelvic pain.2,8 Our conceptualization of many psychological sequelae of abuse as maladaptive coping strategies emphasizes the value of multimodal treatment that includes a focus on developing more adaptive ways of coping, especially for the abused subset of this patient population.
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Address reprint requests to:
Robert C. Reiter, MD Department of Obstetrics and Gynecology University of Iowa Hospitals and Clinics 200 Hawkins Drive, Room C505 GH Iowa City, IA 52242-1009 E-mail: [email protected]
Received December 16, 1996. Received in revised form April 28, 1997. Accepted May 2, 1997. Copyright © 1997 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
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